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-773T5 — preventions 


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The  only  real  wealth  is  health. 

The  great  hope  of  modern  medicine  is  the 
prevention  of  disease. — Cabot 


A  POPULAR  TREATISE 


V 


BY 

KENELM  WINSLOW,  B.  A.  S.,  M.  D. 

Attending  Physician  to  Seattle  City  Hospital  and  King  County  Hospital,  Washington; 
formerly  Assistant  Professor  of  Comparative  Therapeutics  at  Harvard  Medical 
School;  formerly  Surgeon  to  Newton  Hospital;  recent  Vice-President  of.  the  American 
Association  for  the  Study  and  Prevention  of  Infant  Mortality;  Author  of  "The 
Production  and  Handling  of  Clean  Milk,"  etc.,  etc. 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS    COMPANY 

1916 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

B      SAUNDERS    COMPANY 
PHILADELPHIA 


HA 


TO 

M.   H. 

IN  APPRECIATION  OF  CONSTANT 
ENCOURAGEMENT  AND  SYMPATHY 
IN  THE  WRITING  OF  THIS  BOOK 


CONTRIBUTORS   OF   INTRODUCTORY 
NOTES 


Charles  H.  Mayo,  A.  M.,  M.D.,  LL.D.,  F.  A.  C.  S., 

President  of  the  American  Medical  Association ;  Surgeon  to  St. 
Mary's  Hospital,  Rochester,  Minnesota. 

Joseph  Colt  Bloodgood,  B.  S.,  M.D.,  F.  A.  C.  S., 

Associate  Professor  of  Clinical  Surgery,  Johns  Hopkins  Uni- 
versity; Associate  Surgeon  Johns  Hopkins,  Union,  Protestant, 
and  St.  Agnes  Hospitals,  Baltimore;  Director  of  the  Amer- 
ican Society  for  the  Control  of  Cancer;  Member  of  the  Amer- 
ican Society  for  Cancer  Research. 

Winfield  Scott  Hall,  M.  S.  (Northwestern),   Ph.D.  (Leipzig),  M.D. 

(Leipzig), 

Professor  of  Physiology,  Northwestern  University;  Fellow 
American  Academy  of  Medicine;  American  Medical  Associa- 
tion; Member  American  Physiological  Society;  American 
Genetic  Association.  Author  of  Text-book  of  Physiology; 
Manual  of  Experimental  Physiology;  Nutrition  and  Dietetics; 
Reproduction  and  Sexual  Hygiene,  etc.,  etc. 

Frederick  Peterson,  M.D.,  Ph.D., 

Ex-President  of  the  New  York  State  Commission  in  Lunacy; 
Former  Professor  of  Psychology  in  Columbia  University; 
Consulting  Alienist  for  Bellevue  Hospital,  New  York;  Man- 
ager of  the  Craig  Colony  For  Epileptics,  at  Son  yea.  New  York. 
Author  of  Mental  Diseases,  American  Text-book  of  Legal 
Medicine  and  Toxicology,  etc.,  etc. 

Charles-Edward  Amory  Winslow,  B.  S.,  M.S., 

Anna  M.  R.  Lauder  Professor  of  Public  Health,  Yale  Medical 
School,  and  Curator  of  Public  Health,  American  Museum  of 
Natural  History,  New  York;  Member  Society  of  American 
Bacteriologists,  American  Society  of  Naturalists,  etc.,  etc. 
Author  of  Elements  of  Water  Bacteriology,  Elements  of  In- 
dustrial Microscopy,  Systematic  Relationship  of  Coccaceac,  etc. 

Joel  E.  Goldthwait,  B.  S.,  M.D.,  F.  A.  C.  S., 

President  of  Corporation  of  Robert  B.  Brigham  Hospital,  Bos- 
ton; Lecturer  on  Orthopedic  Surgery,  Harvard  Medical 
School;  Late  Orthopedic  Surgeon,  Massachusetts  General 
Hospital;  Consulting  Orthopedic  Surgeon  to  Lynn,  Carney, 
Haverhill  Hospitals;  Ex-President  of  the  American  Ortho- 
pedic Association,  etc. 


PREFACE 


"AN  ounce  of  prevention  is  worth  a  pound  of  cure" 
is  a  truly  weighty  maxim,  and  expresses  fairly  accurately 
the  comparative  ratio  of  value  between  curative  and 
preventive  medicine,  i.  e.,  as  16  to  1.  Modern  preventive 
medicine  may  be  said  to  have  begun  with  Sir  Edward 
Jenner  (1796),  who  introduced  vaccination  against  small- 
pox. This  was  founded  solely  upon  the  experience  of  the 
laity,  and  a  whole  century  elapsed  before  another  English- 
man, Sir  Almoth  Wright  (1897),  was  enabled,  through  ad- 
vances in  knowledge  and  his  own  genius,  to  re-introduce 
vaccination  as  a  general  method  of  protection  in  various 
germ  diseases.  At  one  stroke  he  annihilated  the  dangers 
of  a  disease  (typhoid  fever)  whose  bacilli  are  more  fatal 
than  bullets  and  placed  it  in  the  growing  list  of  preventable 
disorders. 

The  meaning  of  vaccination  has  been  amplified,  and 
while  originally  signifying  inoculation  with  a  cow  (vacca) 
virus,  the  term  may  now  be  properly  applied  to  the  use  of 
any  material  for  preventive  inoculation. 

But  this  book  is  not  a  record  of  the  progress  in  preven- 
tive medicine. 

It  is  a  detailed  practical  guide  for  the  layman  that  he 
may  avoid  the  various  diseases  described  herein.  The 


Vlll  PREFACE 

first  three  chapters  are  devoted  to  the  proper  methods  of 
living  in  health  so  as  to  evade  ill  health. 

These  pages  contain  the  essence  of  matters  to  which 
whole  books  are  often  dedicated.  The  matter  on  diet, 
exercise,  tea  and  coffee,  and  alcohol  the  author  believes 
will  prove  of  special  interest  and  worth. 

While  the  secret  of  cancer  remains  to  be  solved,  yet 
recent  knowledge  may  enable  an  individual  to  escape  this 
most  dreaded  and  fatal  malady.  In  fact,  the  importance 
of  this  matter  is  so  great  that  its  discussion  alone  should 
make  a  book  of  this  kind  worth  while. 

In  relation  to  the  germ  diseases,  the  common  methods 
are  considered  whereby  one  may  protect  oneself  or  others. 
The  means  of  preventing  malaria,  colds,  and  the  proper 
diet  and  exercise  in  the  prevention  of  constipation  and 
obesity  should  appeal  to  a  large  number  of  persons.  The 
prevention  of  nervous  disorders  in  children  of  neurotic 
parents  has  a  large  field  of  usefulness  in  this  country. 
The  very  recent  work  of  Billings  and  Rosenow  in  Chicago, 
emphasizing  the  influence  of  diseased  tonsils,  gums  and 
teeth,  and  other  local  infections  in  the  production  of  the 
most  serious  chronic  diseases,  has  been  deemed  worthy 
of  a  special  chapter.  The  use  of  a  new  instrument  of 
precision  in  the  last  decade  for  estimating  blood-pressure 
has  greatly  enlarged  our  knowledge  of  arterial  disease,  or 
premature  old  age,  and  a  chapter  is  devoted  to  this  sub- 
ject. Prevention  of  the  diseases  of  childhood  is  perhaps 
the  most  essential  subject  in  preventive  medicine,  and  a 
chapter  will  be  found  on  this  topic. 


PREFACE  IX 

The  knowledge  that  infant  mortality  results  chiefly 
from  the  feeding  of  raw  cows'  milk  has  enormous  signifi- 
cance. While  there  is  no  specific  for  the  prevention  of 
tuberculosis,  yet  we  believe  that  the  practical  points  given 
in  this  connection  will  be  found  of  much  service. 

The  prevention  of  sexual  diseases  is  a  subject  equally 
disagreeable  and  vital,  and  the  ostrich-like  fashion  of 
ignoring  its  existence  is  both  absurd  and  reprehensible. 

The  author  wishes  to  express  his  sincere  appreciation 
and  hearty  thanks  for  the  kindness  and  generosity  of 
some  of  the  foremost  medical  men  in  America  who  have 
gratuitously  contributed  the  introductory  notes  to  be 
found  in  various  parts  of  this  book. 

This  they  did  to  show  the  laity  that  the  matter  con- 
tained herein  represents  the  sound  and  scientific  opinion 
of  the  leaders  of  the  medical  profession  today. 

These  leaders  would  be-  unwilling  to  lend  their  distin- 
guished names  if  they  did  not  believe  that  the  book 
would  aid  in  bettering  the  lives  of  its  readers. 

This  book  is  not  merely  a  compilation  from  literature, 
but  is  the  outcome  of  a  quarter-century  of  active  medical 
and  surgical  practice  in  the  East  and  West. 

KENELM  WINSLOW. 

SEATTLE,  WASHINGTON, 
November,  1916. 


FOREWORD 


IT  is  very  pleasing  to  find  placed  before  the  people 
such  a  concise  and  simple  description  of  most  of  the 
facts  known  to  modern  preventive  medicine  as  that 
given  in  the  following  pages. 

For  too  long  a  period  medicine  has  been  looked  upon 
as  more  or  less  associated  with  mystery,  and  for  this 
reason  all  sorts  of  mysteries  have  crept  into  it  through 
many  cults  and  isms,  and  many  practices  and  pathies. 

Such  training  in  medicine  as.  it  has  been  possible  for 
the  public  to  receive  has  often  been  obtained  from  the 
direct  advertising  or  faked  medical  news  items  in  the 
papers  and  magazines  of  the  day. 

Never  before  has  there  been  such  a  general  apprecia- 
tion of  preventive  medicine  as  now.  The  present  war 
has  shown  the  possibilities  of  protecting  whole  armies 
from  the  ravages  of  disease. 

By  the  prevention  of  disease  great  enterprises  which 
were  impossible  twenty  years  ago,  such  as  the  building 
of  the  Panama  Canal,  are  now  possible. 

During  the  last  half  century  the  average  duration  of 
human  life  has  been  increased  many  years,  largely 
through  the  protection  of  the  people  by  public  health 
laws. 


Xll  FOREWORD 

The  presentation  of  the  wonderful  advances  of  modern 
medicine  here  given,  together  with  carefully  considered 
rules  for  daily  living  in  order  to  preserve  health,  is  offered 
to  those  who  desire  them,  not  that  they  may  become 
physicians  by  reading  this  matter,  but  that,  from  their 
wider  knowledge  of  science,  they  may  be  better  citizens. 

CHARLES  H.  MAYO. 


PAGE 

FOREWORD  (By  Charles  H.  Mayo) xi 

CHAPTER  I 

PERSONAL  HYGIENE 1 

Tea  and  Coffee,  1 — Alcohol,  5 — Tobacco,  13 — Opium 
and  Cocain,  19. 

CHAPTER  II 

PERSONAL  HYGIENE  (Continued) 20 

Care  of  the  Teeth  and  Mouth,  20 — Pyorrhea  (Riggs' 
Disease),  22 — Hygiene  of  the  Digestion,  25 — Causes  of 
Indigestion,  26 — Cookjng,  29 — Value  of  Food  Elements,  30 
—Meat,  31— Fish,  35— Milk,  36— Eggs,  37— Cereals,  37— 
Fats,  38 — Vegetables  and  Fruits,  39 — Vegetarian  Diet,  4.1 
— Salt,  42 — Water-supply,  43 — Purity  of  Water  and  Ice,  45. 

CHAPTER  III 

PERSONAL  HYGIENE  (Continued) 47 

Exercise,  47 — Special  Exercises  for  Different  Ages,  47 — 
Rationale  of  Exercise,  50 — Clothing,  56 — Baths,  58 — Out- 
door Baths,  59— Lukewarm  and  Warm  Baths,  62 — Hot, 
Turkish,  and  Cabinet  Baths,  63 — Ventilation,  64 — The 
Complexion,  66 — Sunburn,  66 — Freckles,  67 — Acne,  67 — 
Care  of  the  Hair,  68— Baldness  and  Dandruff,  68— Care  of 
the  Finger-nails  and  Toe-nails,  70. 

CHAPTER  IV 

GERM  DISEASES 71 

Vaccination  and  Small-pox.  71 — Typhoid  Fever,  76 — 
Asiatic  Cholera,  82 — Dysentery,  84 — Diphtheria,  86 — Hy- 
drophobia, 92 — Lockjaw,  95 — Scarlet  Fever,  97 — Mea- 
sles, 100 — Mumps,  101 — Whooping-cough,  102 — Bubonic 
Plague,  104. 

xiii 


XIV  CONTENTS 

CHAPTER  V 

PAOB 

GERM  DISEASES  (Continued) 107 

Malaria,  107— Yellow  Fever.  112 — Dengue,  115. 

CHAPTER  VI 

GERM  DISEASES  (Continued) 117 

Tuberculosis,   117 — Colds,   130 — Influenza,    135 — Cere- 
brospinal  Meningitis,  137 — Infantile  Paralysis,  141. 

CHAPTER  VII 

COMMON  LOCAL  TROUBLES  AS  A  SOURCE  OF  SERIOUS  GEN- 
ERAL DISEASES 145 

Importance  of  Infections  of  Nose,  Mouth,  and  Throat, 
145 — Tonsils  and  Adenoids  (Riggs'  Disease),  158. 

CHAPTER  VIII 

PREVENTION  OF  CANCER 160 

Introductory  Note  (By  Joseph  Colt  Bloodgood),  160. 

CHAPTER  EX 

THE   PREVENTION   OF   SEXUAL    DISEASES   AND   SEXUAL  HY- 
GIENE     180 

Introductory  Note  (By  Winfield  Scott  Hall),  180— Sex- 
ual Hygiene  in  Marriage,  197. 

CHAPTER  X 

PREVENTION    OF   ACUTE    AND   CHRONIC    RHEUMATISM    AND 

ACUTE  TONSILLITIS 203 

CHAPTER  XI 

THE  PREVENTION  OF  DISEASES  OF  CHILDREN 213 

Circumcision,   214 — Proper  Food    for   the   Infant,  215 
System,  223 — Vaccination,  226. 

CHAPTER  XII 

THE  PREVENTION  OF  DISEASES  OF   MIDDLE  AGE 228 

Arteriosclerosis,  228 — Heart  Disease,  236 — Bright's  Dis- 
ease of  the  Kidneys,  237— Prevention,  238. 


CONTENTS  XV 

CHAPTER  XIII 

PAGE 

THE  PREVENTION  OF  NERVOUS  AND  MENTAL  DISEASES 246 

Introductory  Note  (By  Frederick  Peterson),  246 — Neu- 
rasthenia, 247 — Hysteria,  Paresis,  Dementia  Prsecox,  Para- 
noia, Mania,  Melancholia,  246. 

CHAPTER  XIV 

THE  PREVENTION  OF  DISEASES  OF  DIGESTION 260 

Constipation,  260— Ulcer,  271,— Gastritis,  272— Gall- 
stone, Appendicitis,  Stone  in  the  Kidney,  272 — Nervous 
Dyspepsia  and  Visceroptosis,  276. 

CHAPTER  XV 

FOOD  POISONING 283 

Introductory  Note  (By  Charles-Edward  Amory  Wins- 
low),  283 — Milk  Poisoning,  284 — Ptomain  Poisoning,  289 
— Meat  Poisoning,  290— Fish  and  Shell-fish  Poisoning,  293 
— Vegetable  and  Fruit  Poisoning,  294. 

CHAPTER  XVI 

DISORDERS  OF  NUTRITION 297 

Beriberi,  297— Scurvy,  301— Rickets,  302— Pellagra,  305 
— Obesity,  307 — Prevention  of  Diabetes,  316. 

CHAPTER  XVII 

THE  PREVENTION  OF  SOME  DEFORMITIES 317 

Introductory  Note  (By  Joel  E.  Goldthwait),  317— Round 
Shoulders  and  Lateral  Curvature  of  the  Spine,  318 — 
Humpback,  321 — Knock-knees  and  Bow-legs,  324 — Weak 
Foot  and  fiat-Foot,  325. 

CHAPTER  XVIII 

PREVENTION  OF  INFECTION  AND  BLEEDING  IN  WOUNDS 330 

Sterilization  with  lodin,  330 — Inflammation,  332 — Steril- 
ization by  Washing,  333 — To  Prevent  Lockjaw,  333 — Spe- 
cial Wounds,  334— Bullet  Wounds,  335— To  Stop  Bleeding, 
336.  

INDEX  .  .   339 


» 

'•*•* 


THE  PREVENTION  OF  DISEASE 


CHAPTER  I 

PERSONAL  HYGIENE 

Tea,  Coffee,  Alcohol,  Tobacco,  Morphin,  and  Cocain 
TEA  AND  COFFEE 

IT  is  a  singular  and  noteworthy  fact  that  there  appears 
to  be  some  instinctive  demand  or  craving  among  human 
kind  for  caffein.  All  over  the  world  natives  have  discov- 
ered and  habitually  drink  beverages  containing  this  active 
principle,  although  the  plants  have  no  common  resem- 
blance and  the  effects  produced  are  not  marked,  as  in  the 
cases  of  alcohol,  opium,  and  hashish. 

Thus,  tea,  coffee,  chocolate,  and  cocoa  all  contain  caffein 
or  allied  bodies — thein  and  theobromin.  Caffein  is  also 
the  active  principle  of  the  African  kola  nut,  of  the  South 
American  guarana  and  mate  tea  (from  a  species  of  holly), 
while  in  the  West  Indies  and  Mexico  the  habitual  beverage 
is  made  from  the  fermented  chocolate  bean. 

Caffein  is  one  of  the  most  powerful  heart  and  nervous 
stimulants  employed  in  medicine.  A  cup  of  coffee  con- 
tains from  1|  to  3  grains  of  this  substance,  a  full  medicinal 
dose.  Tea  contains  1  to  4  per  cent.;  coffee,  0.6  to  2  per 
cent.;  mate,  1.3  per  cent.;  kola,  1  to  2  per  cent.;  guarana, 
3  to  6  per  cent,  of  caffein. 

In  the  roasting  of  coffee  there  is  developed  a  volatile  oil, 
caffeol,  to  which  the  flavor  and  aroma  is  due.  It  is  so 
i  i 


2  THE   PREVENTION   OF   DISEASE 

powerful  that  one  drop  of  caffeol  will  fill  a  room  with 
coffee  odor. 

Tea  naturally  contains  a  volatile  oil  (0.6  per  cent.). 
Both  tea  and  coffee  have  a  considerable  amount  of  tannic 
acid  in  their  composition,  but  that  in  coffee  is  compara- 
tively inert,  although  it  tends  to  impair  digestion  some- 
what. That  in  tea,  however,  is  active  and  astringent, 
and  exerts  a  tanning  effect  upon  the  mucous  membrane  of 
the  stomach  in  strong  solutions.  Neither  coffee  nor  tea 
should  be  boiled  in  their  preparation,  since  the  volatile 
oil,  or  flavor  and  aroma,  are  considerably  lost  in  the  proc- 
ess. Coffee  should  be  made  by  percolation  with  boiling 
water,  or  by  enclosing  coffee  in  a  tea-ball  and  pouring 
boiling  water  over  it  and  allowing  it  to  steep  for  a  few 
minutes.  Tea  is  commonly  made  in  this  fashion  and  is 
permitted  to  steep  from  two  to  five  minutes. 

The  longer  tea  stands  the  darker  it  gets  and  the  more 
tannic  acid  it  contains.  The  confirmed  tea  drinker,  who 
keeps  the  tea  standing  in  the  teapot  all  day  and  drinks  it 
cold,  is  getting  enough  tannin  to  convert  hide  into  leather. 
There  are  but  1  to  2  grains  of  caffein  in  a  cup  of  tea,  as 
less  tea  than  coffee  is  used  to  the  cup. 

The  volatile  oil  in  coffee  stimulates  the  brain,  the 
stomach  and  bowels,  and  in  some  persons  acts  favorably  as 
a  laxative.  In  others,  coffee  causes  overacidity  in  the 
stomach  and  diarrhea  owing  to  this  action.  The  oil  in 
coffee  (said  to  be  about  a  teaspoonful  in  a  cup)  is  probably 
one  reason  for  "biliousness"  which  it  induces  in  some  indi- 
viduals, but  this  is  partly  due  to  the  large  amount  of 
caffeotannin  in  coffee.  Strong  tea,  through  its  active 
tannin,  on  the  other  hand,  lessens  acidity  in  the  stomach 
and  favors  constipation,  although  more  immediately 
stimulating  to  the  brain  than  coffee.  In  nervous  indiges- 
tion and  nervous  conditions  generally  both  tea  and  coffee 


TEA    AND    COFFEE  6 

are  injurious  because  of  the  exciting  action  of  caffein  on 
the  nervous  system.  It  is  a  curious  fact  that  after  drink- 
ing many  cups  of  tea  or  coffee  daily  for  months  or  years  a 
person  may  become  suddenly  oversusceptible  to  their 
influence,  so  that  a  single  cup  may  cause  bad  effects. 
The  same  phenomenon  is  seen  in  the  case  of  tobacco  users. 
It  is  a  matter  of  common  knowledge  that  whereas  one 
person  may  drink  several  cups  of  tea  or  coffee  without 
disturbing  sleep,  in  another  a  single  cup  hours  before  bed- 
time may  keep  him  wide  awake  and  restless  with  active 
mind  most  of  the  night. 

The  action  of  preparations  of  kola  sold  at  the  soda- 
water  fountains  depends  upon  caffein,  and  the  kola  habit  is 
more  prevalent  in  the  South. 

Chocolate  contains  0.3  to  2  per  cent,  of  theobromin  and 
up  to  ^  of  1  per  cent,  of  caffein. 

Chocolate  is  very  rich  in  fat  (30  to  50  per  cent.)  or 
cacao-butter.  In  cocoa  we  have  the  fat  much  reduced 
(15  to  30  per  cent.)  by  its  removal  through  hydraulic 
pressure. 

The  active  principle  of  chocolate  (theobromin)  is  much 
less  stimulating  to  the  brain  than  caffein,  but  has  a  more 
powerful  action  on  the  kidneys.  Chocolate  is  extremely 
nourishing,  but  the  amount  of  fat  and  sugar  in  it  retards 
the  secretion  of  gastric  juice  and  the  motions  of  the 
stomach,  while  its  theobromin  is  apt  to  cause  loss  of  appe- 
tite. Cocoa  is  less  prone  to  disturb  digestion  by  containing 
less  fat,  while  the  cheaper  kinds  are  mixed  with  starch,  and 
so  hold  less  theobromin.  Some  cocoas  have  the  fat  in  a 
more  digestible  form  by  treating  them  with  an  alkali  by 
the  Dutch  process.-  Phillips'  digestible  cocoa  is  especially 
suited  for  those  with  weak  digestions.  While  cocoa  is  a 
valuable  and  very  nutritious  beverage  for  the  invalid, 
chocolate  is  too  rich  and  sweet  to  be  digestible.  A  heaping 


4  THE    PREVENTION   OF   DISEASE 

teaspoonful  of  cocoa  and  sugar  added  to  milk  nearly 
doubles  its  food  value.  Cocoa  should  be  boiled  five 
minutes  to  cook  the  raw  starch  (10  per  cent.).  It  also 
contains  about  15  per  cent,  of  protein. 

Action. — Now  as  to  the  general  physiologic  action  of  the 
caffein-containing  beverages:  Caffein  is  an  active  stimu- 
lant to  the  brain,  heart,  and  muscles. 

It  enables  persons  under  its  influence  to  do  more  and 
better  mental  work.  It  increases  the  perception  and 
association  of  ideas  and  the  acuteness  of  the  senses,  as  the 
sense  of  touch.  In  thus  sharpening  the  intellect  caffein  is 
directly  opposed  to  alcohol.  It  more  nearly  resembles 
strychnin  in  action,  and  in  poisonous  doses  renders  the 
nervous  system  so  acute  to  stimulation  that  a  touch  on  the 
skin  may  throw  an  animal  into  convulsions.  It  has  been 
found  experimentally  that  stenographers  will  do  more, 
better,  and  speedier  work  after  one  cup  of  coffee  than  with- 
out any,  and  fatigue  does  not  follow  the  extra  work. 
Larger  doses  of  caffein  retard  the  speed,  but  do  not  impair 
the  quality  of  the  work.  Many  experiments  have  shown 
that  soldiers  march  longer  without  fatigue  under  the  in- 
fluence of  caffein  or  coffee.  It  stimulates  the  muscles 
directly  as  well  as  the  nervous  system.  For  any  especial 
mental  effort,  as  in  taking  an  examination,  coffee  in 
moderate  amount  (one  or  two  cups)  will  enable  one  to  do 
better  work,  but  the  continued  use  of  it  for  night-study  only 
leads  to  nervousness  and  mental  confusion. 

The  bad  effects  of  the  tea  and  coffee  habit  are  seen 
especially  in  nervous,  sedentary,  underfed,  anemic,  and 
debilitated  persons.  The  symptoms  include  insomnia, 
trembling  of  the  hands,  palpitation  of 'the  heart,  noises  in 
the  ears  or  head,  pain  in  the  stomach  or  heart-burn,  rapid, 
irregular  pulse,  neuralgia  and  headaches,  general  nervous- 
ness, and  (from  tea)  constipation.  Poor  and  underfed 


ALCOHOL  5 

women  are  specially  prone  to  the  tea  habit.  In  all  cases 
of  insomnia,  dyspepsia,  and  nervousness  the  first  thought 
should  be  to  stop  the  use  of  coffee  and  tea. 

Caffein  is  used  in  medicine  chiefly  as  a  rapidly  acting 
heart  stimulant,  often  injected  under  the  skin,  and  also  to 
stimulate  the  action  of  the  kidneys. 

The  habitual  use  of  tea  and  coffee,  like  that  of  tobacco, 
does  not  improve  the  health.  A  single  cup  of  either  taken 
daily  will  not  perceptibly  injure  the  health  of  most  normal 
persons.  Used  to  excess  and  by  susceptible  persons  the 
harm  done  by  tea  and  coffee  is  immense.  The  race  would 
be  better  off  without  either,  and  the  young  should  be  dis- 
couraged from  initiating  the  habit. 

ALCOHOL 

The  action  of  alcoholic  drinks  depends  chiefly  upon  the 
amount  of  alcohol  they  contain.  Ale,  stout,  beer,  and 
porter  contain  from  3  to  7  per  cent,  of  alcohol.  The 
bitter  they  hold  (hops)  tends  to  improve  the  appetite, 
but  the  sugar  and  starchy  matter  may  cause  gas  in  the 
bowels.  The  older,  and  darker  foreign  beers  appear  to 
produce  much  less  of  this  fermentation  in  the  bowels  and 
are  less  apt  to  cause  "biliousness"  and  indigestion. 

The  lighter  wines  contain  from  7  to  15  per  cent,  of  alco- 
hol, more  often  12  to  14  per  cent.,  as  California  clarets, 
Madeira,  muscatel,  sherry  and  Riesling,  and  the  Rhine 
and  Hungarian  wines. 

The  yeast  plant,  which  produces  wine  by  the  fermenta- 
tion of  saccharine  grape  juices,  is  itself  killed  by  an  amount 
of  alcohol  much  over  15  per  cent.,  and  so  the  stronger  wines 
are  fortified — that  is,  have  alcohol  added  to  them  in  the 
form  of  distilled  liquor  from  grapes,  figs,  raisins,  or  sweet 
potatoes. 

The  fortified  wines  are  imported  sherry,  port,  and  Ma- 


6  THE   PREVENTION    OF   DISEASE 

deira,  and  contain  from  17  to  25,  or  even  30  per  cent.,  of 
alcohol. 

Champagne  is  considered  one  of  the  most  stimulating 
wines,  and  yet  contains  but  about  10  per  cent,  of  alcohol. 
It,  like  some  kinds  of  Burgundy,  is  called  a  sparkling  wine 
on  account  of  being  charged  with  carbonic  acid  gas. 

It  stimulates  the  stomach  and  its  effect  is  much  more 
rapid,  for  the  reason  that  it  reflexly  stimulates  the  heart 
(through  stimulation  of  the  stomach),  and  by  increasing 
the  blood-supply  and  movements  of  the  stomach  leads  to 
more  rapid  absorption.  Somewhat  the  same  effect  is 
seen  when  whisky  is  mixed  with  soda  water. 

The  bouquet  of  wines  is  due  to  the  development  of 
special  alcohols,  or  esters,  by  long  standing.  A  red  wine 
is  prepared  by  fermentation  of  the  juice  of  red  grapes  with 
their  skins.  If  it  contains  much  tannin  it  is  said  to  be 
rough.  White  wines,  as  Sauterne,  Chablis,  Riesling,  are 
made  from  grapes  freed  from  seeds,  skins  and  stems,  and 
usually  contain  no  tannic  acid.  A  dry  wine  contains  little 
sugar,  it  having  been  all  fermented  into  alcohol,  while  a 
sweet  wine  contains  free  sugar. 

Distilled  liquors  or  spirits  are  made  by  distilling  any 
fermented  liquor.  Alcohols,  volatile  acids,  and  ethers 
are  found  in  distilled  liquors.  Distilled  liquors  should 
age  (over  four  years)  in  order  that  the  bouquet  may  de- 
velop from  the  action  of  the  acid  on  the  alcohol  and  form 
esters.  Also  that  the  fusel  oil  may  escape,  which  causes 
the  after-headache  from  new  whisky.  Distilled  liquors 
are  made  from  fermented  grains  (corn,  rye,  wheat,  barley), 
as  whisky  and  gin,  and  from  fermented  fruit  juices,  as 
brandies.  Ordinary  brandy  or  Cognac  is  distilled  from 
wine;  and  peach,  pear,  and  apple  brandy  from  fermented 
juice  of  these  fruits.  The  distilled  liquors  contain  from 
45  to  55  per  cent,  of  alcohol.  Rum  is  distilled  from  fer- 


ALCOHOL  / 

mented  molasses.  Scotch  and  Irish  whisky  have  a  smoky 
taste  from  being  distilled  over  peat  fires,  or  from  being 
made  from  malt  dried  over  peat  fires.  Gin  is  distilled 
from  fermented  rye,  and  then  redistilled  with  juniper 
berries,  which  makes  it  more  useful  in  relieving  pain,  and 
it  is  much  used  by  women  for  this  purpose  during  men- 
struation. 

Cordials  are  artificial  mixtures  of  aromatics,  sugar, 
alcohol,  and  water.  They  contain  from  50  per  cent. 
(Chartreuse)  to  67  per  cent,  of  alcohol  (absinthe)  and  over 
30  per  cent,  of  sugar.  Absinthe  has  a  peculiarly  bad 
effect  upon  the  brain,  causing  mental  depression,  convul- 
sions, and  insanity  in  habitues.  Many  countries  forbid  its 
manufacture,  and  the  United  States  its  importation  since 
1912.  The  great  amount  of  sugar  and  alcohol  in  cordials 
produces  a  very  injurious  action  on  the  stomach. 

Experimental  researches  concerning  alcohol  have  quite 
altered  the  attitude  of  the  medical  profession  toward  it 
during  the  last  decades.  As  a  direct  consequence,  its  use 
in  treatment  of  disease  is  as  rare  today  as  it  was  formerly 
common.  Our  knowledge  and  ideas  have  changed,  par- 
ticularly in  reference  to  the  so-called  stimulant  effect  of 
alcohol  and  its  action  as  a  food. 

By  stimulant  action  one  may  refer  to  stimulation  of  the 
nervous  system  or  circulation. 

Action  of  Alcohol. — We  will  first  consider  the  action  of 
alcohol  on  the  nervous  system.  We  now  know  that  alco- 
hol, instead  of  being  a  stimulant,  is  a  powerful  depressant 
or  narcotic  (producing  stupor)  to  the  nervous  system, 
beginning  with  depression  of  the  most  highly  developed 
functions  of  the  brain  and  continuing  until  there  is  loss  of 
consciousness,  motion,  sensation,  and  even  paralysis  of  the 
first-formed  (in  course  of  evolution)  and  most  vital  centers 
at  the  base  of  the  brain,  so  that  we  have  failure  of  respira- 


8  THE    PREVENTION    OF   DISEASE 

tion  and  circulation  in  alcoholic  poisoning,  or  drunkenness. 
In  fact,  alcohol  acts  like  ether,  only  its  action  is  much 
slower,  because  it  has  to  be  absorbed  from  the  stomach  in- 
stead of  being  absorbed  in  the  form  of  vapor  by  the  lungs. 

It  is  a  well-known  physiologic  fact  that  the  functions 
of  the  brain  which  have  most  recently  developed  in  the 
evolutionary  course  of  ages  are  the  first  to  succumb  to  the 
action  of  drugs.  Alcohol  decreases  or  depresses  the  higher 
brain  functions  of  will,  self-control,  reason  and  judg- 
ment, and  sets  us  back  on  the  animal  plane.  This  is  seen 
in  the  conduct  of  one  under  the  influence  of  alcohol,  when 
modesty  is  lost,  demeanor  and  speech  become  free  and 
uncontrolled  (in  vino  veritas),  and  the  subject  is  thought- 
less of  others,  is  reckless,  oversanguine  and  confident,  and 
deficient  in  reasoning  power  and  judgment. 

The  false  feeling  of  stimulation  comes  from  the  more 
ready  effect  of  outside  stimuli,  as  through  mental  excite- 
ment produced  by  social  intercourse,  the  warmth  of  the 
skin  and  stomach,  and  enhanced  emotional  and  imagina- 
tive functions.  In  many  persons,  especially  when  alone, 
and  in  animals  alcohol  only  produces  depression,  dulness, 
and  stupor  from  the  start,  and  is  frequently  used  for  this 
reason  to  overcome  sleeplessness. 

The  depression  of  the  higher  brain  centers  by  alcohol  is 
also  seen  in  the  impairment  of  sight,  hearing,  and  touch, 
although  the  subject  feels  that  the  contrary  is  true.  Type- 
setters make  more  errors,  musicians  strike  more  false 
notes  under  alcohol.  On  the  other  hand,  muscular  power 
is  increased  for  a  short  time  (up  to  half  an  hour)  by  alcohol, 
but  later  there  is  a  corresponding  loss  of  strength — as  great 
as  50  per  cent,  sometimes.  For  sustained  effort  alcohol 
is  inadvisable.  Soldiers  endure  longer  on  the  march  with- 
out it,  and  the  Germans  have  found  that  sugar  or  chocolate 
is  superior. 


ALCOHOL  9 

The  removal  of  abnormal  constraint  and  self-conscious- 
ness by  alcohol  may  be  of  advantage  to  public  speakers,  in 
allowing  greater  freedom  of  speech  and  gestures,  and  in 
giving  the  musician  greater  power  of  emotional  expression 
and^abandon.  But  the  danger  of  overstepping  the  mark 
and  producing  stupefaction,  and  the  greater  peril  of  form- 
ing an  unconquerable  habit,  make  such  use  of  alcohol 
unwise. 

In  removing  the  normal  restraint  exercised  by  the  brain 
over  the  sexual  desires  alcohol  is  the  chief  means  of  leading 
youth  into  immorality.  This  it  does  in  two  ways — first,  by 
diminishing  the  will  power,  and,  second,  by  increasing  the 
animal  desires — hence,  "weib"  is  the  natural  corollary  of 
"wein"  ("wein,  weib,  und  gesang"). 

The  word  "stimulant"  is  almost  synonymous  with  alco- 
hol in  the  popular  mind.  In  reference  to  the  circulation,  al- 
cohol in  concentration  (as  when  whisky  or  brandy  are  given 
with  an  equal  amount  of  water)  stimulates  the  heart  by 
irritating  the  mouth  and  throat.  This  stimulation  is 
marked,  yet  lasts  but  a  few  moments.  After  the  alcohol 
is  absorbed  it  has  very  slight  stimulating  effect  on  the 
heart. 

Alcohol  is  no  longer  habitually  employed  as  a  heart 
stimulant  in  fevers,  exhausting  disease,  and  conditions  of 
acute  heart  weakness  (pneumonia),  but  is  one  of  the  best 
agents  for  use  by  the  layman  in  emergencies,  for  its  fleeting, 
stimulant  action  in  faintness,  after  emotional  and  nervous 
shocks,  and  after  accidents.  But  do  not  give  such  an 
amount  as  to  depress  and  intoxicate  the  patient,  as  only 
too  frequently  results  from  the  overwillingness  of  the 
anxious  layman.  Two  to  four  tablespoonfuls  of  whisky  or 
brandy,  with  an  equal  amount  of  water,  constitute  a  suit- 
able dose. 

The  action  of  alcohol  in  imparting  a  sensation  of  warmth 


10  THE    PREVENTION    OF   DISEASE 

to  the  skin,  stomach,  and  face  gives  one  a  false  sense  of  its 
stimulating  effect.  This  is  not  stimulation,  but  dilatation 
of  the  blood-vessels.  So  far  from  being  an  evidence  of 
stimulation,  relaxation  of  the  vessels  results  in  fainting  from 
lack  of  blood  in  the  brain,  if  excessive.  The  injurious  action 
of  alcohol  in  those  exposed  to  cold  is  accounted  for  by  its 
influence  on  the  blood-vessels.  The  lowest  temperatures 
ever  seen  in  the  human  body  have  occurred  in  intoxicated 
persons  exposed  to  cold.  Alcohol  is  tabooed  in  Arctic 
exploration  on  this  account.  By  dilating  the  blood-vessels 
of  the  skin  alcohol  permits  of  the  largest  amount  of  cooling 
of  the  blood  by  external  cold. 

There  is  the  now  classic  example  of  the  effect  of  alcohol 
upon  an  Alpine  party,  spending  the  night  at  a  high  altitude 
after  a  hard  day's  climb,  related  by  Brunton.  Some  of  the 
party  refused  alcohol  and  turned  in  cold  and  miserable; 
others  drank  whisky  in  moderation,  and  retired  feeling 
wanner  and  more  comfortable;  while  the  remainder  par- 
took freely  and  slept  oblivious  to  all  hardship.  In  the 
morning  those  who  had  refrained  from  alcohol  awoke 
refreshed  and  well,  those  who  had  taken  a  small  amount 
of  alcohol  found  themselves  cold  and  wretched,  while 
those  who  had  indulged  freely  did  not  awake  at  all  because 
they  were  dead. 

The  only  time  that  alcohol  is  indicated  in  such  cases  is 
after  the  exposure  to  cold  is  past  and  when  one  enters  a 
warm  house  or  bed. 

Then  one  may  overcome  the  chilliness  by  a  glass  of  hot 
water  and  whisky,  and  perhaps  prevent  "taking  cold"  by 
dilating  the  vessels  on  the  surface  of  the  body,  thus  re- 
storing the  circulation  to  normal  or  equalizing  the 
circulation. 

Alcohol  has  been  truthfully  called  both  a  food  and  a 
poison — usually  by  opposing  advocates.  It  is  both.  It 


ALCOHOL  11 

may  take  the  place  of  starch  and  fat  as  a  nutrient  by  sup- 
plying energy  in  its  combusion  in  the  body,  but  without 
requiring  any  digestive  action  of  the  stomach.  Thus,  in 
states  of  severe  exhaustion  or  disease,  or  following  great 
muscular  or  nervous  strain,  and  in  the  aged  it  may  be  used 
to  advantage  as  a  food. 

In  continued  fevers  alcohol  is  employed  for  this  purpose 
and  for  its  narcotic  action  in  allaying  nervousness,  rest- 
lessness, and  in  promoting  sleep. 

Alcohol  excites  the  appetite  and  enables  one  to  eat  more 
than  is  good  for  him.  It  does  not  affect  digestion  notably, 
unless  in  the  case  of  strong  alcoholic  liquors,  which  increase 
the  acid  of  the  gastric  juice  and  favor  the  occurrence  of 
gastric  catarrh.  The  starchy  matters  in  malt  liquors  and 
acids  in  some  wines  may  retard  digestion.  The  continu- 
ous use  of  alcohol  as  a  beverage  must  be  condemned  from 
the  food  viewpoint  because  it  destroys  the  vital  organs, 
produces  chronic  inflammation  of  the  stomach,  and  tends 
toward  dulness  and  lessened  capacity  for  muscular  or 
mental  work  and  results  in  a  vicious  habit.  So  it  is 
probable  that  those  who  call  alcohol  a  poison  are  nearer 
the  truth  than  those  who  affirm  it  to  be  a  food. 

It  is  a  common  experience  among  humans,  and  is  as 
frequently  seen  in  experiments  upon  rabbits,  that  some 
individuals  may  drink  large  quantities  of  alcohol  for 
years  without  inducing  perceptible  deterioration  of  their 
vital  organs. 

Others  soon  break  down  with  various  disorders — fatty 
degeneration  of  the  heart,  liver,  and  kidneys,  hardening 
of  the  liver  (cirrhosis)  and  arteries,  Bright's  disease  of  the 
kidneys  in  some  cases,  and  chronic  catarrh  of  the  stomach. 
Inflammation  and  degeneration  of  the  nervous  system  are 
common — meningitis,  neuritis  (inflammation  of  the  surface 
of  the  brain  and  nerves) ,  and  hardening  of  the  brain  and 


12  THE   PREVENTION   OF  DISEASE 

spinal  cord.  Great  nervousness,  insomnia,  digestive  dis- 
turbance, or  pain  in  the  legs  or  elsewhere  (neuritis)  are 
the  symptoms  which  bring  the  drinker  to  the  doctor. 

To  realize  most  poignantly  the  enormous  number  of 
persons  wrecked  by  alcohol  one  should  be  attending  physi- 
cian at  a  large  city  hospital. 

The  ordinary  well-to-do  and  well-behaved  individual  has 
no  means  of  appreciating  the  true  significance  of  drink. 
Daily  to  see  innumerable  patients  with  delirium  tremens 
and  its  immediate  sequel  ("wet  brain")  in  the  more  invet- 
erate cases,  with  death  or  insanity  resulting  as  a  matter  of 
course,  has  a  most  impressive  influence  upon  the  Jeast 
thoughtful.  The  insane  asylum  is  another  splendid  place 
to  view  the  end-results  of  alcohol  in  the  subject  or  his 
progeny.  Alcohol  renders  persons  less  resistant  to  infec- 
tions, notably  consumption  and  pneumonia.  The  latter 
is  also  a  peculiarly  fatal  disorder  in  the  alcoholic. 

While  scientists  may  differ  as  to  many  details  concern- 
ing alcohol,  there  are  some  basic  facts  upon  which  all  are 
agreed.  These  are  as  follows:  That  alcohol  is  not  of  bene- 
fit to  any  healthy  person  under  normal  conditions.  That 
the  habitual  use  of  a  moderate  amount  of  alcohol,  or  the 
occasional  use  of  an  excessive  quantity  of  alcohol,  is  dam- 
aging to  the  health  of  normal  individuals.  That  while  the 
moderate  and  occasional  employment  of  alcohol  by  most 
persons  will  produce  no  visible  harm,  in  others  there  is 
such  an  inherent  and  inborn  demand  for  alcohol  that  it  is 
impossible  for  them  to  take  it  in  moderation,  and  an  in- 
curable habit  results.  While  technically  a  food,  its  intrin- 
sic harmfulness  is  so  great  that  alcohol  may  with  pro- 
priety be  termed  a  poison.  It  is  especially  damaging  to 
women  and  children,  though  it  may  be  of  positive  benefit 
to  the  aged.  As  a  stimulant,  alcohol  may  be  used  to  ad- 
vantage for  its  immediate  effect  in  reflexly  stimulating  the 


TOBACCO  13 

heart  in  emergencies  (through  its  irritation  of  the  mouth 
and  throat  before  absorption).  Its  use  as  a  stimulant  after 
absorption  from  the  stomach  has  been  given  up  because 
such  action  does  not  exist  to  any  extent.  It  is  not  a  stimu- 
lant, but  a  stupifierof  the  nervous  system,  and  its  medicinal 
influence  in  this  direction  is  taken  advantage  of  for  the 
production  of  sleep  and  quieting  nervous  excitement  and 
restlessness.  Its  frequent  use  for  any  reason  is  dangerous 
in  establishing  a  vicious  habit. 

Perhaps  one  of  the  most  impressive  statements  concern- 
ing the  effect  of  a  moderate  use  of  alcohol  is  found  in  that 
made  by  the  actuary  of  the  New  York  Life  Insurance  Co., 
who  affirms  that  among  the  dpaths  of  2,000,000  policy- 
holders  during  a  period  of  twenty-five  years  the  "total 
abstainers  have  a  mortality  during  the  working  years  of 
life  of  about  one-half  that  among  those  who  use  alcohol  to 
the  extent  of  at  least  two  glasses  of  whisky  daily." 

The  world-wide  prohibition  movement  depends  upon 
the  exact  knowledge  of  alcohol  derived  from  the  experi- 
ments and  experience  of  the  medical  profession,  and  its 
altered  attitude  in  respect  to  the  use  of  alcohol,  more  than 
upon  any  other  factor. 

TOBACCO 

Tobacco  is  essentially  a  narcotic.  In  large  amounts 
narcotics  (as  bromids,  opium,  alcohol)  produce  stupor  and 
unconsciousness,  but  in  small  doses  are  sedative  and  sooth- 
ing. Thus  it  is  with  tobacco.  The  narcotic  influence  is 
exerted  upon  the  brain.  The  action  of  tobacco  upon  the 
circulation  consists  first  in  slowing  and  strengthening  the 
heart  and  contracting  the  blood-vessels,  but  this  effect  is 
soon  followed  by  depression  and  increased  frequency  of  the 
heart  and  dilatation  of  the  blood-vessels.  After- ^action 
comes  reaction,  and  long  after  the  influence  of  tobacco  just 


14  THE    PREVENTION    OF   DISEASE 

described  has  worn  off  there  is  a  period  of  nervous  irrita- 
bility and  instability. 

This  is  the  "morning  after"  phenomenon,  as  seen  fol- 
lowing excessive  smoking,  more  especially  when  the  habit 
is  suddenly  stopped. 

The  ill  effects  of  the  abuse  of  tobacco  are  well  established 
and  are  briefly  as  follows:  (1)  Disturbance  of  the  cir- 
culation. This  is  more  commonly  evidenced  by  pain  about 
the  heart  and  a  feeling  of  fluttering  or  beating  in  this 
region,  with  shortness  of  breath  on  exertion  and  rapid, 
irregular  pulse.  In  some  cases  the  pulse  may  be  slow  and 
the  blood-pressure  unusually  low.  (2)  Disturbance  of  the 
nervous  system.  Headaches,  dizziness,  and  a  tremulous 
condition  of  the  hands  are  often  observed.  Lack  of  energy 
and  ambition,  together  with  nervous  irritability  and  men- 
tal depression,  result  from  overuse  of  tobacco.  (3)  Various 
forms  of  indigestion  may  be  occasioned  by  excessive  smok- 
ing, particularly  that  accompanied  by  increased  acidity  in 
the  stomach  and  heart-burn.  (4)  The  paralyzing  action 
on  special  nerves.  This  is  occasionally  seen  in  partial 
blindness  or  deafness,  owing  to  the  direct  action  of  nico- 
tin  upon  the  optic  or  auditory  nerves.  In  this  form  of 
blindness  the  patient  can  see  better  in  a  dim  light.  (5) 
Local  action  of  tobacco  smoke.  Tobacco  smoke  irritates 
the  throat  and  also  the  eustachian  tubes,  which  connect  the 
upper  part  of  the  throat  with  the  middle  ear.  In  this 
way  deafness  from  catarrh  of  the  middle  ear  is  not  infre- 
quently produced  by  excessive  smoking. 

Cigarette  smokers  have  often  a  loud,  ringing  or  barking, 
dry  cough,  with  harshness  or  hoarseness  of  voice  from  the 
effects  of  the  smoke  upon  the  vocal  cords.  Then,  in  so- 
called  "smoker's  tongue"  there  are  formed  white  patches 
(leukoplakia)  not  only  on  the  tongue,  but  also  upon  the 
inside  of  the  cheeks  in  some  cases.  One  of  these  patches 


TOBACCO  15 

is  very  prone  to  become  cancerous  after  years  unless  smok- 
ing is  stopped  and  treatment  begun.  Cancer  of  the  lower 
lip,  seen  almost  wholly  in  men,  is  thought  to  be  due  to 
pressure  of  a  pipe-stem.  Of  course,  it  goes  without  saying 
that  these  troubles  are  not  frequent  occurrences  in  indi- 
vidual smokers,  or  the  hafoit  would  soon  lose  favor,  but,  in 
the  aggregate,  there  are  great  numbers  of  such  cases.  One 
can  never  tell  where  the  lightning  will  strike.  The  dis- 
orders caused  by  tobacco  are  usually  cured  by  complete 
abstention  from  its  use,  and  by  living  in  a  healthy  manner, 
with  plenty  of  outdoor  exercise  and  sleep. 

But,  since  these  troubles  may  also  be  attributed  to  other 
causes,  it  will  be  impossible  for  a  doctor  to  be  sure  that 
tobacco  is  the  source  of  any  disorder  until  after  complete 
abstention  from  the  weed  for  weeks. 

•  There  are  still  other  serious  physical  and  moral  dangers 
threatening  the  young  who  use  tobacco.  In  a  study  of  the 
students  at  Yale  and  Amherst  it  has  been  found  that 
smokers  are  stunted  in  height,  weight,  and  chest  measure 
as  compared  to  non-smoking  students.  Meylan,  at  Co- 
lumbia, concluded  from  a  careful  investigation  that  the 
use  of  tobacco  among  the  students  leads  to  idleness,  lack 
of  application,  ambition,  and  scholarship. 

Charles  B.  Towns,  who  is  the  most  celebrated  specialist 
in  drug  habits  in  this  country,  insists  that  the  harm  done 
by  tobacco  is  greater  in  the  aggregate  than  that  from  alco- 
hol, cocain  and  opium,  and  that  "nothing  else  at  the  pres- 
ent time  is  contributing  so  surely  to  the  degeneration  of 
mankind  as  tobacco." 

This  may  seem  like  an  extreme  statement,  but  Towns 
finds  that  he  can  rarely  cure  the  alcoholic  unless  the  patient 
gives  up  smoking,  because  the  smoker  finds  that  alcohol  is . 
necessary  to  relieve  the  irritability  and  nervous  depression 
caused  by  the  excessive  use  of  tobacco. 


16  THE   PREVENTION   OF  DISEASE 

The  bad  moral  effect  of  tobacco  upon  boys  is  brought 
about  in  various  ways.  They  are  often  forced  to  smoke 
surreptitiously,  and  to  do  this  frequent  the  tobacco 
shop,  pool,  or  barroom,  where  they  obtain  cigarettes 
and  are  naturally  dragged  downward  by  their  surround- 
ings. 

A  few  words  as  to  the  composition  of  tobacco  and  the 
effect  of  different  methods  of  using  it.  The  chief  constit- 
uent is  one  of  the  most  powerful  poisons  known  (nicotin), 
an  oily,  colorless,  pungent,  volatile  liquid,  existing  to  the 
extent  of  from  1  to  7  per  cent,  in  tobacco.  Virginia 
tobacco  is  one  of  the  strongest.  The  taste  and  flavor  of 
tobacco  depend  upon  the  development  of  a  volatile  oil  in 
the  curing.  The  injury  arising  from  tobacco  is  due  to 
nicotin  and  allied  substances  (pyridin  and  collidin),  and 
also  to  furfurol,  an  ingredient  of  fusel  oil  in  raw  whisky, 
which  causes  the  headache  and  other  bad  after-effects. 
But  much  of  the  nicotin  is  destroyed  by  its  combustion  in 
smoking,  and  there  is  said  to  be  no  furfurol  in  most  of  the 
Turkish  tobacco  ("London  Lancet"). 

The  harmfulness  of  smoking  depends  in  part  upon  the 
amount  of  nicotin  in  the  smoke.  There  is  least  in  cigar- 
ette smoke  and  most  in  pipe  smoke,  while  the  smoke  from 
cigars  occupies  an  intermediate  place.  It  has  been  found 
that  even  when  the  same  amount  of  tobacco  is  smoked  in 
the  form  of  a  cigarette  and  cigar,  and  the  cigarette  tobacco 
is  much  the  richer  in  nicotin,  the  resulting  cigarette  smoke 
contains  considerably  less  nicotin  than  the  smoke  from 
the  cigar.  This  follows  because  in  the  cigarette  the  to- 
bacco is  finer  and  drier  and  in  a  form  to  burn  completely. 
In  the  cigar,  especially  if  green  and  moist,  the  nicotin 
volatilizes  in  the  damp  area  behind  the  flame  and  is  in- 
haled in  the  smoke.  The  black,  moist,  acrid  mixture  of 
tobacco  and  saliva  in  the  bowl  of  an  old  pipe  distils  off  its 


TOBACCO  17 

nicotin  when  it  becomes  hot  and  produces  the  strongest 
smoke.  The  thinner  and  drier  a  cigar,  the  milder  it  is, 
because  of  its  more  complete  combustion. 

But  cigarettes  are  most  pernicious  in  their  general 
results  chiefly  because  they  are  so  mild  that  their  smoke  is 
almost  always  inhaled.  Inhalation  increases  the  effect 
of  nicotin  many  times.  The  area  with  which  the  smoke 
comes  in  contact  in  the  lungs  is  enormous,  and  the  lungs  are 
made  for  absorption  of  gas  (air),  and  the  action  is  extremely 
rapid. 

The  opium  habitue  long  ago  discovered  that  he  got  more 
speedy  and  effective  action  by  smoking  than  by  swallowing 
the  drug.  Then,  again,  the  cheapness  and  mildness  of 
cigarettes  causes  them  to  be  smoked  at  all  available  mo- 
ments, when  a  pipe  or  a  cigar  would  require  too  much  time 
or  expense.  This  applies  particularly  to  boys,  who  now 
take  more  frequently  to  cigarettes,  when  formerly  they 
would  have  had  to  smoke  cigars  or  pipes.  The  danger  of 
the  overwhelming  nausea  and  depression,  and  the  expense 
involved  in  the  use  of  these,  was  a  great  natural  preventive 
which  has  been  done  away  with  in  the  introduction  of  the 
cigarette. 

Cigarettes  are  most  injurious,  then,  on  account  of  the 
custom  of  inhaling  their  smoke  and  the  temptation  to 
smoke  them  continuously.  There  is  about  as  much 
tobacco  in  one  cigar  as  in  five  or  six  cigarettes. 

Smoking  is  partly  a  narcotic,  or  drug  habit  and  partly 
a  psychic  habit.  The  narcotic  effect  is  seen  in  its  soothing, 
comforting  action,  in  its  relieving  anxiety  and  worry,  and 
inducing  a  pleasant  frame  of  mind.  Its  psychic  influence 
is  brought  about  by  holding  an  object  in  the  mouth  (as  is 
seen  in  the  marvelous  influence  of  sucking  a  blind  nipple 
in  the  case  of  an  infant),  by  the  rhythmic  inhalation  and 
exhalation  of  the  smoke,  and  by  the  hypnotic  effect  in 
2 


18  THE   PREVENTION   OF   DISEASE 

watching  the  smoke  curl  into  fascinating  and  fantastic 
shapes  and  rings. 

The  physiologic  demand  of  the  system  for  tobacco  is 
not  so  great  as  that  for  alcohol,  cocain,  or  opium  in 
habitue's.  In  other  words,  on  stopping  the  use  of  tobacco 
part  of  the  craving  is  psychic,  and  this  may  be  relieved  by 
chewing  gum,  gentian,  quassia,  or  lovage.  The  actual 
demand  of  the  system  for  the  drug  effect  of  tobacco  can 
then  be  resisted  without  great  force  of  will,  except  in  the 
case  of  the  inveterate  smoker.  One  who  smokes  one 
cigar  daily  after  dinner  may  be  classed  a  moderate  smoker. 
The  harmful  effect  of  smoking  is  much  less  after  a  hearty 
meal. 

The  most  practical  result  of  smoking  is  lessened  personal 
efficiency.  Towns  goes  so  far  as  to  state  that  smoking 
diminishes  the  efficiency  of  an  individual  about  15  per 
cent.  Smoking  is  indubitably  opposed  to  the  highest  de- 
velopment of  vigor  and  energy,  or  "pep,"  to  use  the  pic- 
turesque slang  of  the  day.  This  result  must  be  presented 
forcibly  to  the  youth  who  naturally  desires  to  succeed  in 
business  and  sports. 

Tennis  and  billiard  players  know  that  smoking  inter- 
feres with  their  accuracy  of  play  and  nervous  power. 

The  matter  of  tobacco  is  in  like  case  with  other  harmful 
habits,  for  no  sensible  person  will  affirm  that  smoking 
improves  the  health.  Then  it  simply  becomes  a  question 
as  to  how  much  injury  tobacco  does.  This  depends  upon 
the  personal  constitution,  the  amount  of  nicotin  absorbed, 
and  the  occupation.  Its  effects  may  be  imperceptible  in  a 
parent,  and  yet  lead  to  defective  nervous  organization  in 
the  offspring,  as  is  indisputably  true  of  alcohol.  If  we  are 
smokers,  we  must  confess  ourselves  fools  to  our  sons  in 
order  that  they  may  improve  upon  their  fathers. 


OPIUM   AND    COCAIN  19 

OPIUM  AND  COCAIN 

•  Prevention  of  the  morphin  and  cocain  habits  lies  largely 
with  the  medical  profession.  Morphin  is  taken  by  means 
of  the  hypodermic  syringe  in  most  cases.  It  is  first  given 
by  physicians  for  the  relief  of  pain.  After  morphin  has 
been  administered  for  a  month  the  patient  has  acquired  the 
habit  and  will  need  outside  assistance  to  free  himself  from 
it,  even  if  he  is  no  longer  in  pain  from  other  causes. 
Statutes  to  prevent  the  purchase  of  the  hypodermic  syr- 
inge should  be  enacted.  Only  in  New  York  at  present 
does  such  a  law  exist,  owing  to  the  benevolent  energy  of 
Charles  B.  Towns.  Physicians  should  hesitate  to  inject 
morphin  except  for  unbearable  pain  of  short  duration. 
They  should  never  entrust  a  patient  with  a  hypodermic 
syringe  except  under  most  unusual  circumstances.  There 
appear  to  be  over  100,000  opium  habitues  in  the  United 
States,  averaging  over  8  grains  of  morphin  as  a  daily 
dose. 

The  cocain  habit  is  begun  because  of  the  exhilaration 
and  relief  afforded  when  the  drug  is  used  by  doctors  for 
treatment  of  cold  in  the  head  or  other  nasal  troubles. 

It  is  very  stimulating  for  a  short  time,  and  depression, 
which  follows  within  about  twenty  minutes,  excites  a 
demand  for  more.  It  is  the  most  difficult  of  all  habits  to 
break.  Patent  remedies  containing  morphin  and  cocain 
are  also  responsible  for  initiating  the  habit. 

Members  of  the  underworld  acquire  the  morphin  and 
cocain  habits  from  association  with  habitues.  It  is  pos- 
sibly kinder  to  the  race  to  let  them  perish  as  soon  as  pos- 
sible. Most  of  the  other  thousands  of  drug  addicts  in  this 
country  are  to  be  pitied  and  deserve  treatment  at  the  best 
hands.  Their  suffering  is  incredible,  and  nobody  desires 
a  cure  more  than  the  patient  himself. 


CHAPTER  II 

PERSONAL  HYGIENE  (Continued) 

Care  of  the  Teeth  and  Mouth:  Pyorrhea  (Riggs'  Disease). 
Hygiene  of  the  Digestion :  Causes  of  Indigestion,  Cooking,  Value  of 
Food  Elements,  Meat,  Fish,  Milk,  Eggs,  Cereals,  Fats,  Vegetables, 
Fruits,  Vegetarian  Diet,  Salt,  Necessity  of  Water,  Purity  of  Water 
and  Ice. 

CARE  OF  THE  TEETH  AND  MOUTH 

THE  care  of  the  teeth  and  mouth  has  taken  on  a  new 
significance  of  late  owing  to  great  progress  in  treatment  of 
abnormal  conditions,  and  because  it  has  become  evident 
that  inflammations  in  the  mouth — including  decay  of  the 
teeth,  and  inflammation  of  the  gums  and  tonsils — are  the 
cause  of  many  serious  remote  diseases.  These  include  acute 
rheumatism,  chronic  joint  diseases,  heart  disease,  etc.  In 
fact,  because  of  the  importance  of  this  subject  a  separate 
chapter  is  devoted  to  it  in  another  place  (see  p.  145). 

Care  of  the  teeth  has  hitherto  been  chiefly  directed  to- 
ward the  prevention  of  decay,  but  it  is  of  the  greatest  con- 
sequence that  irregularities  of  the  teeth  and  jaws  should  be 
avoided  in  childhood. 

It  is  thought  that  adenoid  growths,  so  common  in  chil- 
dren, produce  a  narrow  upper  jaw  with  a  high  or  gothic 
roof  of  the  mouth,  and  it  is  also  probable  that  our  use 
of  soft,  prepared  foods  in  modern  life  leads  to  disuse  of 
the  jaws  and  their  muscles,  so  that  the  jaws  are  not  large 
enough  to  contain  the  teeth.  It  is  certainly  a  striking  fact 
that  the  fine,  large,  impressive  jaws  of  our  ancestors  are  not 
so  commonly  seen  today.  The  first  teeth  must  be  watched 
20 


CARE    OF  THE   TEETH   AND    MOUTH  21 

so  that  the  second  teeth  may  come  regularly,  or  otherwise 
deformity  of  the  jaw  may  be  produced.  Too  early  or 
late  loss  of  the  first  teeth  disturb  the  eruption  of  the 
permanent  teeth.  If  one  jaw  is  narrow,  its  teeth  will 
not  meet  those  of  the  other  jaw,  and  the  deformed 
jaw  must  be  spread  by  the  dentist.  A  narrowing  of  the 
upper  jaw,  with  high,  arched  roof  of  the  mouth,  inter- 
feres with  the  breathing  through  the  nose,  and  may 
thus  lead  to  adenoid  growth  and  pinched  nostrils.  Tonsils 
and  adenoids  must  be  removed  to  prevent  extension  of  in- 
flammation from  them  into  the  eustachian  tubes  which 
lead  to  the  ears.  Deafness  in  children,  recurring  colds, 
abscess  of  the  ears,  and  mastoid  disease  of  the  bone  of  the 
skull  behind  the  ears  are  usually  caused  by  diseased  tonsils 
and  adenoids. 

.  Protrusion  of  the  teeth  of  the  upper  jaw  may  be  induced 
by  the  habit  of  thumb-sucking  in  infants.  Extra  or  super- 
numerary teeth  constitute  another  cause  of  irregularity  of 
the  jaws.  One  must  pay  particular  attention  to  the  teeth 
during  the  period  from  the  seventh  to  fourteenth  years  of 
childhood,  as  this  is  the  time  for  the  dentist  to  care  for  the 
first  teeth  and  prevent  their  early  decay,  or  straighten 
the  teeth  by  methods  which  have  reached  such  a  state  of 
perfection  that  they  have  become  a  specialty  (ortho- 
dontia).  Irregularities  of  the  teeth  produce  spaces  in 
which  food  lodges  and  thus  favor  decay.  It  has  only 
recently  been  recognized  by  dentists  that  the  prevention 
of  decay  is  attained  chiefly  by  regularity  and  perfect  polish 
of  the  teeth.  If  the  surface  oT  the  enamel  is  wholly  free 
from  irregularities  and  roughness  there  is  no  chance  for 
food  to  stick  to  them  and  one  might  almost  do  without  a 
tooth-brush.  The  advance  in  this  branch  of  dentistry  has 
been  so  great  that  now  there  are  dental  (prophylactic) 
assistants  who  spend  their  whole  time  in  polishing  the 


22  THE   PREVENTION    OF   DISEASE 

teeth,  removing  tartar,  etc.  This  is  the  ideal  method  of 
caring  for  the  teeth,  and  the  children  of  the  present  day 
will  have  their  children  treated  in  this  way.  A  person 
should  visit  a  dentist  every  month  for  this  purpose,  and 
although  this  seems  a  costly  and  onerous  duty,  yet  the 
ultimate  saving  in  health,  suffering,  and  money  will  easily 
pay  for  the  extra  trouble  required. 

The  teeth  should  properly  be  brushed  after  each  meal 
and  certainly  once  daily,  before  bedtime,  as  that  is  most 
important  in  preventing  a  long  delay  of  food  on  the  teeth. 
The  brush  should  be  rather  soft,  so  as  not  to  injure  the 
gums,  and  have  bristles  of  varying  length  to  reach  into 
irregular  spaces.  The  brush  should  not  be  used  as  if  it 
were  a  blacking  brush,  but  more  like  a  clothes  brush,  to 
brush  the  food  out  of  the  crevices.  The  brush  should  be 
kept  in  a  corked  test-tube  or  bottle  containing  70  per 
cent,  alcohol.  Dental  floss  and  toothpicks  may  injure  the 
gums  and  should  only  be  used  when  absolutely  required. 
Twice  a  week  the  enamel  should  be  rubbed  smooth  with  a 
soft  orange  stick  and  tooth  powder,  unless  one  has  the 
teeth  cleaned  regularly  by  a  dentist,  which  is  preferable. 
Our  American  dentists  have  an  enviable  reputation  every- 
where. The  lack  of  care  of  the  teeth  and  throat  in  child- 
hood is  very  noticeable  in  the  English,  who  frequently  have 
false  teeth  in  early  adult  life,  and  whose  projecting  upper 
teeth,  narrow  upper  jaws,  and  pinched  nostrils  show  in- 
disputably the  end-results  of  want  of  efficient  dentistry 
and  surgery  of  adenoids  and  tonsils. 

Riggs'  Disease. — Very  common  in  adult  life  is  Riggs' 
disease  (or  pyorrhea  alveolaris),  an  inflammation  of  the 
membrane  (peridental  membrane)  which  surrounds  the 
roots  of  the  teeth  beneath  the  gums. 

It  always  begins,  however,  as  an  inflammation  of  the 
free  border  of  the  gums  where  they  join  the  teeth.  As  the 


CARE    OF   THE   TEETH    AND    MOUTH  23 

mouth  usually  contains  some  fifteen  varieties  of  bacteria 
(including  the  pus  germs  or  staphylococci  and  strepto- 
cocci), besides  many  other  accidental  organisms,  there  is 
only  required  some  mechanical  injury  to  the  gums  for 
inflammation  to  follow.  First,  the  essential  cause,  the 
pus  germ;  and  next,  the  predisposing  cause,  usually  local 
irritation  or  general  disease  with  reduced  vitality  of  the 
gums.  Recently  it  has  been  claimed  that  Riggs'  disease  is 
always  due  to  a  special  germ  (entameba)  which  may 
readily  be  destroyed  by  a  special  remedy  (ipecac),  but 
much  doubt  exists  as  to  the  correctness  of  this  assertion. 

Among  the  common  causes  of  irritation  of  the  gums,  and 
so  Riggs'  disease,  are  poor  dentistry,  allowing  spaces  to 
occur  between  the  teeth  in  which  food  may  collect;  ill- 
fitting  crowns  and  bridges;  and  the  accumulation  of 
tartar  on  the  teeth  at  the  edge  of  the  gums.  Constant 
preventive  care  of  the  teeth  by  a  competent  dentist 
will  avert  all  these  causes  of  inflammation  of  the  gums, 
which,  nevertheless,  occurs  in  95  per  cent,  of  adults 
(Black).  Other  causes  of  gum  inflammations  are  the  use 
of  toothpicks,  hard  tooth-brushes,  hot  soup,  tea  or  coffee, 
and  injuries  from  sharp  teeth  and  hard  food.  Bright's 
disease,  tuberculosis,  diabetes,  and  old  age  favor  inflamma- 
tion of  the  gums  by  reducing  resistance  of  the  tissues. 

Some  swelling  of  the  gums  occurs  which  gives  rise  to  a 
space  or  pocket  between  the  gum  and  the  tooth.  The 
formation  of  a  pocket  in  the  gum  is  most  favorable  for  the 
growth  of  germs.  The  gums  then  become  red  and  swollen 
and  more  or  less  painful,  and  matter  or  pus  may  be  pressed 
out  from  these  pockets  as  a  small,  whitish  bead  on  the 
edge  of  the  gums.  If  Riggs'  disease  is  allowed  to  progress, 
the  inflammation  extends  down  along  the  membrane  and 
hard  substance  (cement)  covering  the  roots  of  the  teeth, 
the  gums  recede,  the  roots  of  the  teeth  are  exposed,  and  the 


24  THE   PREVENTION   OF   DISEASE 

teeth  loosen  and  ultimately  drop  out.  An  acute  and 
chronic  form  are  seen.  The  acute  form  occurs  in  fevers 
and  other  special  infections  or  may  be  excited  by  local  irri- 
tation from  any  of  the  causes  noted  above.  The  chronic 
form  is  much  more  common  from  the  irritation  of  food 
between  the  teeth,  bad  dentistry,  etc.,  as  noted. 

As  germs  may  be  absorbed  from  the  inflamed  gums  and 
pass  through  the  blood  into  most  remote  organs,  there 
giving  rise  to  most  serious  disease  of  the  heart,  joints,  kid- 
neys, stomach,  gall-bladder,  appendix,  etc.  (p.  146),  the 
prevention  and  cure  of  Riggs'  disease  is  most  important. 

Prevention  and  cure  go  hand  in  hand.  All  means  of 
preventing  irritation  of  the  gums  are  essential,  and  there- 
fore the  avoidance  of  very  hot  food  and  the  use  of  tooth- 
picks, and  injury  to  the  gums  by  stumps  of  teeth,  ill-fitting 
crowns,  and  bridges.  The  constant  cleaning  of  the  teeth 
(by  a  dentist)  to  prevent  the  accumulation  of  tartar,  and 
skilful  dentistry  to  avoid  spaces  between  the  teeth  for  col- 
lection of  food,  etc.,  are  essential.  When  the  disease  has 
actually  appeared  the  dentist  removes  tartar  from  the 
teeth,  and  if  there  are  pus-pockets  in  the  gum  he  must  treat 
these  so  the  lining  of  the  pocket  is  destroyed,  that  union 
between  it  and  the  membrane  surrounding  the  root  of  the 
tooth  may  occur.  No  tooth  should  be  treated  (except 
to  remove  tartar  from  the  neck  of  the  tooth)  unless  there 
is  a  pocket  in  the  gum.  If  this  were  attempted  the  dentist 
would  actually  make  pockets  which  did  not  previously 
exist.  But,  when  all  is  said  and  done,  the  treatment  of 
pyorrhea  is  very  unsatisfactory.  The  pus-pockets  may  be 
made  cleaner  and  the  condition  alleviated,  not  cured. 
The  teeth  are  more  or  less  destroyed  and  cannot  be  made 
whole  again.  In  bad  cases,  with  great  recession  of  the 
gums,  exposing  largely  the  roots  of  the  teeth,  only  extrac- 
tion will  cure.  Prevention  in  treating  the  early  inflam- 


HYGIENE    OF   THE   DIGESTION  25 

mation  of  the  gums  by  efficient  dentistry  (which  means 
constant  supervision  of  the  teeth)  is  the  chief  desideratum. 
Finally,  it  may  be  desirable  to  treat  the  secondary  infec- 
tion with  pus  germs  by  the  injection  of  vaccines  (made 
from  killed  cultures  of  these  germs)  in  bad  cases  with  pus- 
pockets. 

HYGIENE  OF  THE  DIGESTION 

Digestion  should  begin  in  the  mouth;  that  is,  the  prepa- 
ration of  food  for  absorption  should  begin  in  the  mouth 
through  proper  chewing,  thus  mixing  the  food  with  saliva, 
which  digests  cooked  starchy  food  or  changes  it  into  malt 
sugar.  This  takes  place  chiefly  during  the  first  half-hour 
or  so  after  arrival  of  food  in  the  stomach,  because  the  stay 
in  the  mouth  is  too  short.  After  this  time  the  acid  gastric 
juice  saturates  the  food  in  the  stomach  and  stops  the  action 
of  saliva.  The  digestion  of  unboiled  starch  by  saliva  is 
slight,  and  such  largely  passes  through  the  intestines 
unchanged  and  may  produce  digestive  disturbance,  as 
seen  in  feeding  raw  bananas  to  infants  or  after  eating  raw 
chestnuts  and  vegetables.  Dogs  have  no  digestive  sub- 
stance or  ferment  (ptyalin)  in  their  saliva,  and  it  is  thought 
that  the  main  use  of  saliva  consists  in  moistening  food  and 
facilitating  chewing  and  swallowing.  When  food  is 
swallowed  in  lumps  they  irritate  the  stomach  and  are  not 
readily  permeated  by  gastric  juice.  The  x-ray  has  shown 
that  one  harm  in  hasty  eating  lies  in  too  rapid  distention 
of  the  stomach  with  food  and  air,  which  may  produce  pain. 

Fletcherizing  of  food,  on  the  other  hand,  is  undesirable, 
and  some  disorders  of  the  stomach  are  attributed  to  too 
prolonged  mastication. 

The  necessity  for  the  presence  of  a  large  proportion  of 
the  teeth  in  order  that  chewing  may  be  properly  accom- 
plished is  usually  accepted,  and  the  loss  of  most  of  the 
opposing  teeth  has  been  considered  a  fruitful  source  of 


26  THE    PREVENTION    OF   DISEASE 

indigestion.  One  of  the  leading  medical  authorities  of 
this  country  (Richard  Cabot)  affirms  that  he  has  never 
seen  a  case  of  indigestion  he  could  attribute  to  Joss  of 
teeth.  The  mouth  ts  inhabited  by  germs,  and  fifteen  to 
thirty  varieties  have  been  found  in  it.  What  is  much 
more  important  (according  to  Charles  Mayo),  pus  germs 
exist  in  80  per  cent,  of  mouths  (staphylococci  and  strepto- 
cocci), and  these  are  usually  responsible  for  the  inflamma- 
tion of  gums  and  tonsils  and  abscesses  about  the  teeth,  and 
they  may  enter  the  blood  and  cause  serious  diseases  of  the 
most  vital  organs  (see  p.  145).  Moreover,  the  saliva 
should  normally  be  neutral  or  alkaline,  but  probably  over 
80  per  cent,  of  people  have  mouths  which  are  not  healthy 
(presence  of  pus  germs),  and  these  are  apt  to  have  an  acid 
reaction  in  their  saliva.  Acid  secretion  is  irritating  and 
there  is  even  danger  of  cancerous  growth  in  the  mouth  from 
prolonged  influence  of  acid.  The  healthy  mouth  is  of  great 
importance  and  largely  depends  upon  proper  care  of  the 
teeth  and  throat  (modern  dentistry  and  removal  of  ade- 
noids and  diseased  tonsils). 

Causes  of  Indigestion. — In  another  place  we  have  taken 
this  matter  up  in  detail.  There  we  have  divided  the 
causes  of  indigestion  into  four  categories.  It  is  in  connec- 
tion with  the  cases  of  faulty  physique,  and  in  those  with 
inherited  nervous  weakness,  that  disturbance  of  digestion 
from  slight  causes  is  likely  to  occur.  These  constitute 
about  one-third  of  all  cases  of  dyspepsia,  and  are  to  be 
classed  under  nervous  indigestion  and  that  due  to  dis- 
placement of  the  stomach  and  intestines. 

Any  extra  strain  borne  by  the  nervous  system,  as  anx- 
iety, worry,  overfatigue,  lack  of  exercise  or  work,  abuse  of 
tobacco,  tea  or  coffee,  sexual  excesses,  insomnia  and  emo- 
tional excitement,  especially  near  or  at  meal  times,  favor 
the  incidence  of  dyspepsia  in  such  persons. 


HYGIENE    OF   THE    DIGESTION  27 

Among  causes  of  indigestion  to  which  all  are  susceptible 
may  be  named  overeating,  irregularity  in  the  time  of 
eating,  improperly  cooked  or  unpalatable  food,  unpleasant 
surroundings,  hasty  eating  or  eating  alone,  which  is  often 
the  same  thing,  and  abuse  of  alcohol.  Drinking  large 
amounts  of  water  at  meals  dilutes  the  digestive  juices  and 
is  undesirable.  The  desire  for  food,  which  includes 
appetite,  palatability,  and  all  the  circumstances  which 
make  eating  pleasant,  as  attractive  service,  agreeable 
company,  a  care-free  mind,  etc.,  have  the  most  important 
influence  upon  digestion.  Indeed,  it  has  been  found 
experimentally  that  "as  the  mouth  waters"  in  anticipation 
of  food,  so  does  the  gastric  juice  flow. 

A  piece  of  meat  held  before  a  dog  which  he  cannot 
swallow,  or  a  piece  that  is  swallowed  but  escapes  into 
the  outer  world  through  a  false  opening  in  the  gullet, 
will  produce  as  much  primary  flow  of  gastric  juice  as  if 
the  food  entered  the  stomach. 

Therefore  the  first  phase  in  the  secretion  of  gastric  juice 
is  brought  about  wholly  through  the  nervous  system  by  the 
desire  for  food.  It  can  be  readily  appreciated  how  unpleas- 
ant emotions  may  have  the  opposite  effect  and  check  the 
nervous  secretion  (through  the  vagi)  and  so  digestion. 
The  second  phase  of  secretion  and  digestion  in  the  stom- 
ach is  due  to  the  presence  of  food  in  the  stomach.  There  is 
a  wonderful  automatic  mechanism  by  which  the  stomach 
contents  escape  and  the  intestinal  secretion  is  regulated. 
As  soon  as  a  jet  of  the  acid  fluid  contents  of  the  stomach 
escapes  into  the  small  intestine  (in  which  the  secretion  is 
alkaline)  the  acid  in  the  bowel  stimulates  a  nervous  action, 
so  that  the  outlet  of  the  stomach  closes  until  the  gastric 
juice  is  neutralized  by  the  alkali  in  the  bowel,  when  the 
outlet  again  relaxes  and  another  jet  of  stomach  contents 
flows  into  the  intestine.  Thus,  there  is  a  continual  auto- 


28  THE   PREVENTION   OF  DISEASE 

matic  opening  and  closing  of  the  stomac.h  outlet  during 
stomach  digestion.  But  this  is  onjy  part  of  the  effect  of  the 
acid  on  the  bowel,  for  each  time  that  acid  flows  from  the 
stomach  into  the  bowels  it  causes  the  formation  of  a  sub- 
stance (secretm)  in  the  wall  of  the  intestine.  This  js 
absorbed  into  the  blood  and  stimulates  the  secretion  of 
bile  and  of  the  gland  (pancreas),  emptying  alkaline  juice 
into  the  intestine.  This  chain  of  events  continues  until 
the  stomach  is  empty,  and  thus  the  flow  of  alkali  is 
automatically  regulated  by  that  of  acid. 

The  two  great  factors  in  digestion  are  secretion  and 
movements  of  the  stomach  and  bowel  pressing  the  con- 
tents along.  The  state  of  secretion  in  the  stomach  is 
precisely  known  by  examination  of  the  stomach  contents, 
while  the  movements  of  the  stomach  and  bowels  are  seen 
by  use  of  the  x-ray.  These  two  methods  of  diagnosis  are 
indispensable  in  chronic  indigestion.  Normal  movements 
of  the  stomach  consist  of  wave-like  contractions,  originat- 
ing every  ten  to  twenty  seconds  after  the  food  enters  the 
organ,  serving  to  mix  the  contents  with  the  gastric  juice 
and  propel  them  on  into  the  bowel. 

Intestinal  digestion  is  brought  about  by  the  entrance 
of  alkaline  digestive  juice  from  the  pancreas  and  bi]e  from 
the  liver,  through  a  duct  about  as  large  as  a  pencil,  entering 
the  intestines  a  few  inches  below  the  stomach  outjet.  The 
walls  of  the  intestines  themselves  furnish  an  important 
secretion  besides.  Intestinal  digestion  is  more  important 
than  that  in  the  stomach,  because  all  elements  of  food 
are  digested  by  the  alkaline  juice  here,  while  in  the 
mouth  £he  cooked  starches  are  only  partly  digested  and 
in  the  stomach  only  proteins.  Moreover,  an  animal  may 
live  with  a  large  part  of  the  stomach  removed.  When 
through  surgical  operation  an  artificial  passage  exists 
between  the  small  intestine  and  the  outside  of  the  body, 


HYGIENE    OF    THE    DIGESTION  29 

so  as  to  drain  off  its  contents,  death  speedily  occurs  with 
great  emaciation. 

Cooking  has,  of  course,  an  enormous  influence  in  in- 
creasing the  digestibility  of  most  food.  In  vegetables 
there  is  a  large  amount  of  starchy  matter.  By  heat 
the  enveloping  membrane  of  the  starch  granules  is  rup- 
tured and  the  starch  thus  is  put  in  a  state  to  be  readily 
acted  upon  by  the  digestive  juices.  Frying  food  in  a  fry- 
ing pan  (sauteing)  tends  to  saturate  it  with  grease  and  to 
make  it  denser  and  harder,  while  frying  in  deep  boiling 
fat  (at  200°  F.)  causes  an  instant  hardening  of  the  surface 
in  a  uniform  coat  that,  with  the  steam  generated  by  the 
moisture  inside,  keeps  the  food  from  being  saturated  with 
fat.  When  a  food  is  saturated  with  fat  the  digestive  juices 
cannot  penetrate  or  act  upon  it  readily,  so  that  frying  in 
deep  fat  is  preferable  to  sauteing.  Pastry  is  indigestible 
owing  to  its  richness  in  fat.  Broiling  is,  on  the  whole, 
better  than  frying,  therefore,  and  baking  is  preferable  to 
boiling  by  keeping  in  the  flavoring  substances  which  may 
be  dissolved  out  in  boiling.  When  meat  or  fish  are  to  be 
roasted,  broiled,  or  fried,  a  high  temperature  should  be  ap- 
plied in  the  beginning  that  an  immediate  coating  be  formed 
to  retain  the  natural  juices,  while  the  cooking  may  be 
continued  with  more  moderate  heat.  In  making  stews  or 
soups  the  opposite  course  is  proper. 

In  making  stews  the  meat  is  placed  in  enough  cold  water 
to  cover  it>  and  it  is  allowed  to  cook  very  slowly  until  it 
reaches  the  boiling-point,  and  then  is  removed  to  the 
back  of  the  stove  to  simmer  till  thoroughly  tender. 

In  order  to  extract  all  the  juice  from  meat  for  soup  or 
beef-tea  it  is  cut  up  and  placed  in  cold  water,  or  water  at 
a  simmering  point,  for  several  hours. 

If  food  is  taken  very  hot  or  cold  the  activity  of  the  gastric 
juice  is  somewhat  impaired. 


30  THE   PREVENTION   OF   DISEASE 

In  the  process  of  digestion  the  food  is  rendered  fluid  and 
soluble  so  that  it  may  be  absorbed  by  the  blood-vessels 
of  the  intestines.  There  is  practically  no  absorption  of 
food  or  water  in  the  stomach  which  pass  on  into  the 
bowels.  The  undigested  and  unabsorbed  food  is  gradually 
propelled  by  the  movements  of  the  intestines,  and  the 
watery  portion  absorbed,  so  that  it  becomes  a  soft  solid 
mixed  with  cast-off  cells  from  the  lining  mucous  membrane 
and  bacteria  (composing  a  large  proportion  of  its  bulk)  in 
the  lower  or  large  intestine.  A  food  is  as  much  outside  the 
body  when  in  the  stomach  or  bowels  as  if  it  were  on  the 
skin,  so  far  as  its  nutritive  value  is  concerned,  unless  it 
becomes  digested  and  absorbed. 

The  elements  of  food,  or  nutrients,  as  they  are  called, 
consist  of  carbohydrates  (starches,  sugars,  and  vegetable 
fiber),  fats,  proteins,  salts,  and  water.  Any  food  contain- 
ing all  these  in  proper  proportion  to  support  life  indefi- 
nitely is  called  a  complete  food.  Milk  is  perhaps  the  best 
example  of  a  complete  food,  but  contains  too  much  water 
for  an  adult.  The  curd  of  sour  milk  (from  which  the 
watery  portion  is  squeezed)  consists  of  casein,  and  is  an 
example  of  a  pure  protein  or  nitrogenous  substance. 
Butter  is  almost  the  pure  fat  of  milk,  and  there  is  about  as 
much  carbohydrate,  in  the  form  of  sugar,  as  protein  and 
fat  in  milk  (4  per  cent,  of  each  roughly).  Proteins  are 
represented  in  animal  food  by  lean  meat,  the  curd  of  milk, 
and  eggs,  which  also  contain  in  the  yolk  considerable  fat. 
Vegetable  food  also  contains  protein,  but  not  so  much,  in 
proportion  to  its  bulk,  as  meat  and  eggs.  So  to  get  as 
much  protein  nourishment  in  a  vegetable  as  in  a  meat  diet 
one  has  to  consume  more  than  is  comfortably  possible 
— without  the  addition  of  cheese,  eggs,  and  milk.  The 
nearest  approach  to  meat,  in  vegetable  food,  are  dried 
peas  and  beans  and  nuts,  and  these  contain  approximately 


HYGIENE    OF   THE    DIGESTION  31 

the  same  amount  of  protein  as  meat  (about  20  per  cent.). 
But  meat  is  more  digestible  and  less  bulky  than  peas  or 
beans,  for  the  percentage  of  protein  is  estimated  by  weight. 
Bread  contains  about  8  per  cent,  of  protein.  Boiled  eggs 
contain  about  13  per  cent,  of  protein,  but  cheese  contains 
25  to  30  per  cent,  and  is  readily  digestible j  Oatmeal  is 
also  rich  in  protein  (16  per  cent,  in  dry  meal),  but  when 
boiled  the  percentage  of  protein  is  low  on  account  of  water 
(about  3  per  cent.). 

The  role  of  protein  consists  in  supplying  material  to 
replace  the  waste  of  tissue  in  a  constantly  running  machine 
and  in  forming  new  tissue  in  the  growing  person.  The 
mechanism  of  the  animal  body  is  always  "running,"  and 
an  animal  at  rest  is  like  a  motor-car  at  a  standstill  with  the 
engine  moving.  Therefore  the  animal  at  rest  requires  as 
much  protein,  as  at  light  work,  for  repair  of  the  machine. 

Exposure  to  severe  cold,  hard  work,  growth,  pregnancy, 
and  lactation  ail  demand  an  extra  supply  of  protein. 
Protein,  besides  supplying  material  for  building  new  tissue, 
yields  heat  and  energy  by  being  burnt  up,  chiefly  in  the 
muscles.  It  may  also  be  transformed  into  fat,  and  a  dog 
may  live  on  lean  meat  for  months  and  gain  in  weight. 

Meat. — Proteins  constitute  the  most  expensive  element 
in  foods,  particularly  the  concentrated  form  in  which  they 
exist  in  meat,  fish,  and  eggs.  Looking  at  meat  in  another 
way,  it  is  the  essence  of  nutriment  extracted  from  vege- 
tables. Lean  meat  is  practically  all  protein,  except  50 
per  cent,  of  water.  Comparing  the  different  meats,  we  find 
beef  contains  the  most  nutriment,  but  its  coarser  fiber 
makes  it  a  little  harder  to  digest  than  lamb  or  mutton. 
Mutton  is  more  unpalatable  than  beef  as  a  constant  diet 
because  of  its  stronger  flavor.  Beef  streaked  with  fat  is 
juicier  and  more  palatable  than  lean  meat.  Very  dark  beef 
has  not  been  bled  or  is  diseased,  while  pale  beef  is  not  suffi- 


32  THE   PREVENTION    OF   DISEASE 

ciently  hung — both  are  undesirable.  Veal  is  as  digestible, 
although  slightly  less  nutritious,  than  beef,  mutton,  or 
lamb.  If  veal  is  pale  and  soft  it  is  too  young  (under  a 
month),  but  if  pale  alone  the  animal  has  probably  been 
bled  to  death. 

Pork,  although  a  most  nutritious  meat  on  account  of  its 
fat,  is  rather  indigestible  and  not  fit  for  children  or  those 
with  weak  digestion.  Bacon,  on  the  contrary,  is  both 
highly  nutritious  and  digestible  and  stimulates  the  appe- 
tite. It  is  the  most  suitable  form  of  fat  (with  cream  and 
butter)  to  build  up  thin  persons  and  the  debilitated  with 
feeble  digestion. 

One  often  hears  a  great  distinction  made  between  light 
(veal,  chicken)  and  dark  meat,  the  former  being  advised 
by  some  physicians  in  place  of  red  meat  in  rheumatism, 
gout,  Bright's  disease  of  the  kidneys,  hardening  of  the 
arteries,  etc. 

There  are  certain  nitrogenous  bodies  derived  from  pro- 
teins which  are  thought  to  put  more  work  on  the  kidneys, 
liver,  etc.,  and,  therefore,  are  undesirable  in  disease  of 
these  organs.  These  bodies  are  extractives  and  purins. 
Extractives  give  flavor  to  meat  and  exist  in  large  amounts 
in  meat  extract,  clear  soups,  and  broths.  They  possess 
very  little  nutritive  or  energy  value,  but  stimulate  the 
nervous  system,  appetite,  secretion  of  digestive  juices,  and 
the  combustion  of  other  foods  in  the  body.  Purins  are 
also  nitrogenous  and  protein-like  substances  which  arise 
from  the  cells  of  animals  and  plants.  Sweetbreads,  liver, 
brain,  kidneys,  fish-roe,  caviar,  meat  extracts,  and  broths 
are  particularly  rich  in  purins.  Among  vegetables,  dried 
peas  and  beans  abound  in  purins,  but  are  free  from  ex- 
tractives. Vegetables  contain  no  extractives  found  in 
meat.  As  a  rule,  vegetables  are  comparatively  poor  in 
protein  and  purins,  especially  green  vegetables  and  roots, 


HYGIENE    OF    THE    DIGESTION  33 

as  water  is  their  chief  ingredient.  Thus,  there  is  75  per 
cent,  of  water  in  boiled  potatoes  and  97  per  cent,  in  boiled 
cabbage.  Fish  is  free  from  extractives,  though  almost  as 
rich  in  proteins  and  purins  as  meat.  A  purin-free  diet 
consists  of  eggs,  milk,  butter,  cheese,  sugar,  bread,  rice, 
macaroni,  green  vegetables  and  fruit,  and  this  is  the  diet 
that  is  preferable  where  we  wish  to  exclude  the  proteins  con- 
sidered most  harmful  in  gout,  rheumatism,  Bright's  disease, 
arteriosclerosis,  and  uric-acid  stone.  The  extractives  are 
normally  the  chief  source  of  the  principal  waste-product 
from  proteins  in  the  urine  (urea),  and  purins  are  normally 
the  source  of  the  other  main  protein  waste-product  (uric 
acid).  While  light  meat  of  veal  contains  less  extractives, 
it  holds  more  purins,  as  does  the  flesh  of  most  young  ani- 
mals, and  the  difference  in  the  action  of  light  (veal,  chicken, 
and  turkey)  and  dark  meat  is  negligible.  Fish  is  preferred 
to  meat  in  some  conditions  as  containing  slightly  less 
protein  matter  than  meat,  and  no  extractives.  By  many 
persons  fish  is  considered  more  digestible  than  meat. 
In  general,  meat  has  been  found  more  digestible  by  Chit- 
tenden.  Fish  containing  much  fat,  as  salmon,  mackerel, 
and  halibut,  are  more  nutritious  but  less  digestible  than 
cod,  haddock,  flounder,  and  sole.  For  working  men  fat 
fish  (like  pork)  is  a  most  efficient  form  of  protein. 

The  matter  of  diet  stands  out  saliently  as  one  about 
which  doctors  disagree.  Nevertheless,  normal  persons 
gain  nothing  by  living  on  a  purely  vegetable  diet.  Vege- 
tables are,  as  a  rule,  less  readily  digestible  and  less  stimu- 
lating to  the  nervous  system,  appetite,  and  digestion  than 
meat  and  are  much  more  bulky.  The  bulk,  however,  is 
often  of  great  value  in  those  disposed  to  constipation. 
Limiting  the  amount  of  protein  (fish,  meat,  and  eggs)  is 
only  permissible  in  adult  healthy  persons  and  should  never 
be  practised  in  the  young.  Even  in  the  life  of  sedentary 


34  THE   PREVENTION   OF   DISEASE 

people,  one  of  the  great  living  physiologists  (Starling) 
affirms  that  an  almost  exclusive  protein  diet  may  be  more 
suitable  than  a  regimen  of  sugars  and  starches  (carbohy- 
drates), because  these  require  oxidation  for  their  combus- 
tion in  the  body  and  that  is  chiefly  brought  about  by  exer- 
cise. But  proteins  stimulate  combustion  of  other  food 
stuffs  in  the  body.  It  is  probable  that  the  various  diseases 
of  middle  age  which  are  supposed  to  result  partly  from  ef- 
fect of  the  strain  on  the  kidneys,  liver,  etc.,  in  eliminating 
protein  waste-products,  are  chiefly  due  to  overeating  and 
lack  of  exercise,  for  it  seems  unreasonable  to  assume  that 
these  organs  suffer  from  overactivity  of  their  normal  func- 
tions in  the  elimination  of  natural  waste-products. 

A  mixed  diet  of  meat,  fish,  eggs,  vegetables,  and  fruit 
is  no  doubt  the  best  for  ordinary  healthy  persons. 

Meat  is  the  most  concentrated  form  of  digestible  food. 

It  is  possible  for  persons  to  live  on  meat  and  water  alone, 
as  well  as  animals,  because  it  contains  some  carbohydrate 
in  the  form  of  muscle  sugar. 

It  is  difficult  to  lay  down  any  definite  rules  for  guidance 
as  to  the  use  of  meat.  Some  of  the  highest  medical  author- 
ities believe  meat  to  be  harmful  in  hardening  of  the  arteries, 
yet  there  are  vegetarian  monks  and  natives  of  Oriental  and 
tropical  countries  who  develop  the  most  pronounced  kind 
of  arteriosclerosis  upon  a  strictly  vegetable  regimen. 
And,  on  the  other  hand,  Edward  Stewart  White  records 
that  the  most  robust  and  finely  developed  tribe  in  eastern 
Africa  lives  almost  wholly  on  blood  and  milk.  The 
amount  of  meat  for  daily  consumption  depends  upon  vari- 
ous factors — the  age,  occupation,  and  climate. 

Young,  growing  persons,  those  doing  hard  physical  and 
mental  work,  and  those  who  work  outdoors,  especially  in 
cold  weather,  require  an  abundant  supply  of  meat,  fish, 
and  eggs.  For  most  individuals  leading  a  quiet,  sedentary 


HYGIENE    OF   THE    DIGESTION  35 

life  such  a  regimen  is  unnecessary  and  may  be  injurious. 
As  meat  is  the  most  expensive  food  and  the  most  palatable 
it  is  apt  to  be  consumed  too  freely  by  the  well-to-do.  If 
there  is  a  too  abundant  supply  of  meat,  so  that  its  products 
are  imperfectly  burned  up  in  the  muscles,  certain  diseases 
are  thought  to  result,  as  uric  acid,  stone  in  the  kidney,  and 
possibly  arteriosclerosis,  while  some  forms  of  Bright's  dis- 
ease of  the  kidney  are  most  unfavorably  influenced  by 
meat. 

In  disease  as  in  health,  however,  a  mixed  diet  is  usually 
most  desirable,  and  it  is  very  rarely  that  a  strict  vegetable 
regimen  is  advisable  (without  the  addition  of  at  least  milk, 
eggs,  and  cheese)  except  for  temporary  morbid  conditions. 
As  noted  above,  some  authorities  think  no  meat  should  be 
eaten  in  arteriosclerosis,  and  in  some  stages  of  Bright's  dis- 
ease it  is  harmful,  and  the  same  applies  to  gout  and  stone. 
But  it  seldom  is  necessary  that  even  meat  should  be  per- 
manently abolished  from  the  diet  in  any  disease. 

Fish. — At  one  time  it  was  thought  that  fish  exerted  a 
tonic  effect  on  the  nervous  system  because  of  an  appreciable 
quantity  of  phosphorus  it  contains,  but  this  idea  has  no 
basis  in  fact.  On  the  contrary,  it  is  meat  that  is  somewhat 
stimulating  to  the  nervous  system  through  its  extractives. 
Shellfish,  as  lobsters,  crabs,  oysters,  mussels  and  clams, 
must  be  eaten  very  fresh,  never  after  they  have  been 
killed  more  than  twenty-four  hours.  Crabs  and  lobsters 
occasionally  poison  some  people,  causing  severe  indiges- 
tion and  vomiting,  with  eruptions — as  hives.  Some  cases 
of  typhoid  fever  have  originated  from  eating  raw  oysters 
grown  in  water  polluted  with  sewage.  This  danger  has 
been  generally  prevented,  and  all  cooked  oysters  are  safe 
food,  very  digestible  as  well  as  nutritious,  and  are  one  of 
the  few  foods  which  have  not  enhanced  in  price  of  recent 
years. 


36  THE   PREVENTION    OF   DISEASE 

Milk,  as  we  have  noted,  .contains  an  almost  equal  amount 
(about  4  per  cent.)  of  protein,  fat  and  carbohydrates 
(milk-sugar),  and  about  88  per  cent,  of  water.  In  adults 
milk  is  not  so  completely  digested  as  in  children,  and  the 
bowel  discharges  may  be  rendered  white  from  undigested 
fat.  It  takes  about  3  quarts,  or  15  glasses,  of  milk  daily  to 
support  an  adult  at  light  work,  and  this  large  quantity  of 
milk  is  apt  to  form  curds  in  the  stomach  and  bowels  and 
lead  to  constipation,  or  occasionally  diarrhea.  The  fact 
that  milk  in  ordinary  quantities  is  one  of  the  most  bland, 
digestible,  and  nutritious  foods  makes  it  the  chief  reliance 
in  sickness.  It  is  not  generally  appreciated,  however, 
that  a  glass  of  milk  equals  in  nourishment  2  eggs  or  2 
moderate-sized  potatoes,  or  5  tablespoonfuls  of  cooked 
cereal,  or  2  slices  of  bread,  or  a  large  helping  of  meat, 
according  to  Roseneau. 

Milk  should  be  really  regarded  as  a  solid  food  because  it 
becomes  partially  solid  or  curdled  by  the  acid  in  the  gas- 
tric juice  as  soon  as  it  enters  the  stomach.  To  prevent  the 
formation  of  a  tough  curd  various  means  are  used.  The 
addition  of  one-third  lime-water,  or  one-half  carbonated 
water,  or  a  pinch  of  salt  aid  the  digestibility  of  milk.  A 
teaspoonful  of  liquenzyme  (Wyeth)  added  to  a  glass  of 
milk  may  cause  it  to  agree  with  persons  otherwise  unable 
to  drink  it.  It  is  wiser  not  to  drink  milk  cold  from  the 
ice,  unless  mixed  with  soda-water.  When  digestion  is  very 
feeble,  broths,  meat  juice,  and  white  of  egg  mixed  with 
water  are  more  appropriate  than  milk.  Milk  is  more 
digestible  if  taken  with  some  starchy  food,  as  crackers  or 
toast,  and  with  the  lighter  meals  (breakfast  and  lunch),  or 
between  meals  and  at  bedtime.  For  thin  and  debilitated 
people  the  writer  is  accustomed  to  prescribe  1  pint  each  of 
thick  cream  and  milk  mixed,  1  glass  at  breakfast,  1  glass 
in  the  middle  of  the  morning,  1  glass  at  luncheon,  and  1  at 


HYGIENE    OF   THE    DIGESTION  37 

bedtime.     Within  a  few  months  there  may  be  a  gain  of 
as  much  as  20  pounds. 

It  is  a  curious  fact  that  while  milk  is  par  excellence  the 
food  for  infants  and  invalids,  there  is  none  which  is  so 
dangerous  and  capable  of  causing  the  worst  of  diseases, 
because  it  is  taken  raw  and  forms  such  fine  food  for  disease 
germs  acquired  from  the  cow  and  man.  We  have  gone  into 
this  more  fully  in  another  place,  but  the  only  safeguard, 
no  matter  how  carefully  milk  is  handled  in  white-tiled 
dairies  and  parlor-like  barns,  is  cooking — by  boiling  or 
pasteurizing  (heat  at  145°  F.  for  thirty  minutes,  followed 
by  cooling) .  The  Chinese  put  us  to  shame  in  this  matter 
by  taking  no  raw  food,  not  even  water,  and  so  escape  ty- 
phoid fever,  etc. 

Eggs  form  a  concentrated  food  rich  in  protein  (13  per' 
cent.),  while  the  yolk  is  exceedingly  rich  in  fat  (33  percent.). 
For  this  reason  eggs  do  not  agree  with  some  persons  with 
weak  digestions,  since  the  fat  of  the  yolk  causes  the  sort  of 
indigestion  known  as  biliousness.  The  white  of  egg 
alone,  which  is  practically  pure  protein  (13  per  cent.)  and 
water,  is  often  preferred  for  the  sick,  giving  it  in  milk  as 
egg-nog  or  stirred  up  with  cold  water  and  flavored  with 
lemon  and  sugar.  It  is  the  large  quantity  of  fat  in  the 
yolk  which  produces  distaste  for  a  constant  diet  of  eggs 
in  some  persons.  When  eggs  are  placed  in  boiling  water 
and  allowed  to  stand  in  it  off  the  stove  for  some  ten 
minutes  (coddled  eggs),  or  are  soft  boiled,  they  are  much 
more  digestible  than  when  hard  boiled. 

Cereals. — Vegetables  are  chiefly  rich  in  carbohydrates 
or  starch,  although,  as  has  been  noted,  dried  peas  and 
beans  contain  as  much  protein  as  meat,  and,  in  addi- 
tion, about  50  per  cent,  of  starch.  With  fat  pork,  baked 
beans  forms  a  very  complete,  cheap,  and  nutritious 
food  suitable  for  outdoor  workers.  Soups  of  peas  or 


38  THE   PREVENTION   OF   DISEASE 

beans  are  also  exceedingly  cheap,  palatable,  digestible, 
and  nutritious.  Cereals  contain  from  10  to  16  per  cent, 
of  protein,  the  highest  amount  in  oatmeal.  They  are  com- 
posed chiefly  of  starch;  rice  and  cornmeal  being  lowest 
in  protein  (7  per  cent.),  and  highest  in  carbohydrates 
(78  per  cent.). 

Cereals  are  the  most  concentrated  and  nutritious  of 
vegetables.  Wheat  contains  about  12  per  cent,  of  proteins, 
68  per  cent,  of  carbohydrates,  and  nearly  2  per  cent,  of  fat, 
besides  phosphates  and  other  valuable  salts.  Bread  con- 
sists of  nearly  50  per  cent,  of  starch  and  7  to  8  per  cent,  of 
protein.  Starch  must  be  crushed,  boiled,  or  roasted  to 
break  the  cells  in  which  it  is  found  in  nature  and  so  become 
digestible.  The  new-fashioned  already  cooked,  puffed, 
or  shredded  breakfast  foods  are  not  nearly  so  nutritious  as 
the  older  forms  of  oatmeal,  cracked  wheat,  hominy,  gra- 
ham meal,  and  Indian  meal  because  they  are  too  bulky. 

Whole  wheat,  rye,  and  graham  bread  are  especially  use- 
ful in  overcoming  constipation  and  do  not  differ  much  in 
composition  from  white  bread.  There  is  not  enough  pro- 
tein in  cereals  to  form  a  complete  food  without  the  addi- 
tion of  fat,  hence  the  rationale  of  bread  and  butter,  but 
even  here  the  bulk  required  is  too  great.  Man  cannot 
live  on  bread  alone,  even  if  it  is  the  staff  of  life. 

The  products  of  digested  starch  and  sugar  are  burned  in 
the  liver  and  muscles  to  produce  heat  and  energy.  Thus, 
while  proteins  build  up  the  bodily  machine  and  supply 
material  to  keep  it  in  repair,  carbohydrates  (starch  and 
sugar)  act  as  fuel.  Carbohydrates  protect  the  more  valu- 
able proteins  from  being  burned  up,  and  are,  to  a  certain 
extent,  transformed  into  fat  in  the  body. 

Fats  are  two  and  one-quarter  times  more  nutritious  than 
carbohydrates;  that  is,  fat  produces  two  and  one-quarter 
times  as  much  heat  in  burning  as  carbohydrates.  Fat  in 


HYGIENE    OF    THE    DIGESTION  39 

the  body  is  chiefly  formed  from  proteins  and  carbohydrates 
in  the  food,  as  the  fat  in  the  food  is  burned  up  for  immedi- 
ate needs  in  the  way  of  heat  and  muscular  action.  Fat  is 
one  of  the  essential  structures  of  the  body  and  acts  as  a 
storehouse,  which  may  be  called  upon  when  the  subject  is 
unable  to  get  sufficient  nourishment  in  disease.  Fat  acts 
as  a  laxative  in  the  bowels,  and  it  is  particularly  valuable 
in  nervous  debility  and  wasting  diseases.  Fats  are  not 
usually  so  digestible  as  most  proteins  and  starches,  but 
those  fluid  at  the  temperature  of  the  body  are  most  readily 
assimilated,  as  butter  and  cream — but  so  is  bacon.  Olive 
oil  is  easily  digestible  for  some  persons  in  quantities  of  a 
teaspoonful  or  more  two  or  three  times  daily,  but  it  often 
acts  as  a  laxative.  It  is  most  easily  assimilated  in  French 
salad  dressing.  Nuts  contain  a  large  percentage  of  fat 
(40  to  60  per  cent.)  and  proteins  (12  to  28  per  cent.),  but 
are  not  particularly  digestible. 

Green  vegetables  and  roots  are  composed  chiefly 
of  water,  but  are  valuable  on  account  of  certain  salts 
they  contain.  The  absence  of  these  leads  to  the  most 
serious  blood  diseases,  as  scurvy,  beri-beri,  etc.  Their 
succulence  and  indigestible  residue  are  also  useful  in  aid- 
ing the  action  of  the  bowels,  while  their  palatibility  is. 
important.  Boiling  is  the  least  suitable  way  of  cooking 
green  vegetables  and  roots  because  it  removes  their  salts, 
unless  the  water  is  used  for  stews  or  soups.  Steaming 
or  roasting  are  preferable. 

Fruits  are  composed  chiefly  of  water,  and  their  nutritive 
value  lies  mainly  in  the  carbohydrates  they  contain,  which 
consist  of  various  sugars,  starch,  and  gums.  In  addition 
to  this,  they  are  rich  in  acids  which,  when  absorbed,  are 
transformed  into  alkaline  salts  (carbonates)  in  the  blood. 
The  acids  in  fruit  consist  of  citric  (in  oranges,  lemons, 
grapefruit,  limes) ;  tartaric  acid  (grape),  malic  acid  (apples, 


40  THE   PREVENTION   OF   DISEASE 

pears,  berries,  rhubarb);  also  acetic  and  oxalic,  and  in 
some  cases  boric  and  salicylic  acids.  The  amount  of  acid 
varies — in  pears,  0.2  per  cent.:  in  apples,  grapes,  plums, 
cherries,  peaches,  strawberries,  0.7  to  0.9  per  cent.;  in 
prunes  and  gooseberries,  1.5  per  cent.;  in  currants,  2.15 
per  cent.;  in  lemons,  6  per  cent. 

Fruits  also  contain  salts  that  are  as  valuable  in  prevent- 
ing blood  diseases  as  are  those  in  fresh  vegetables — e.  g.,  an 
infant  dying  of  scurvy  will  recover  almost  instantaneously 
on  orange  juice.  The  vegetable  fiber  and  acid  in  fruits 
account  for  their  laxative  effect  upon  the  bowels.  The 
composition  of  apples  may  stand  for  that  of  other  fruit. 
They  contain  about  85  per  cent,  of  water,  13  per  cent,  of 
carbohydrates,  and  but  0.4  per  cent,  of  proteins.  A 
fruitarian  diet  has  been  more  or  less  in  vogue  of  late,  in 
which  fruit  is  combined  with  nuts  to  supply  protein.  But 
this  diet  is  then  very  low  in  protein,  and  is  only  suitable 
for  temporary  use  in  persons  who  have  overeaten  or  require 
a  low  protein  diet  for  certain  disorders,  as  intestinal  fer- 
mentation, obesity,  gout,  migraine,  etc.  Raw  fruit  is 
often  undesirable  because  it  is  indigestible  from  being  un- 
derripe, or  poisonous  from  the  presence  of  germs  and 
overripeness.  Persons  with  weak  digestion  and  children 
should  only  eat  cooked  fruit,  with  the  exception  of 
oranges  and  cherries.  Raw  strawberries  are  particularly 
harmful  because  they  grow  on  the  ground  and  may  be 
contaminated  with  intestinal  bacteria  from  animal  or  even 
human  excrement.  They  should  be  stewed.  Raw  apples 
quite  commonly  disagree  with  children  and  adults  with 
weak  digestion.  Bananas  contain  a  large  percentage  of 
raw  starch,  and  the  writer  has  seen  severe  indigestion  and 
even  convulsions  produced  in  infants  by  raw  bananas. 
Baked  bananas  are  very  digestible.  Salted  foods  are  com- 
monly considered  more  indigestible  than  the  same  food 


HYGIENE    OF   THE    DIGESTION  41 

fresh,  as  salt  herring,  salmon,  cod,  salt  pork,  corned  beef, 
etc.  Salt  abstracts  water  from  food,  which,  therefore, 
becomes  drier,  denser,  and  harder.  But  some  food  which 
is  cured  by  salting  and  smoking  is  quite  digestible,  as 
tender  boiled  ham,  which  may  be  eaten  by  persons  with 
feeble  digestion. 

Vegetarian  Diet. — A  final  word  as  to  a  vegetarian  com- 
pared to  a  mixed  diet.  Man  was  made  to  exist  on  a  mixed 
diet,  as  shown  by  his  teeth  and  digestive  apparatus. 
People  who  live  on  a  mixed  diet  are  more  alert,  active,  and 
energetic,  mentally  and  physically,  owing  (probabty)  to 
the  stimulating  effect  of  the  extractives  in  meat  and  to  the 
smaller  bulk  of  mixed  food  requiring  less  energy  for  its 
digestion.  The  same  elements  of  food  exist  in  both  animal 
and  vegetable  diet,  but  the  animal  is  rich  in  proteins  and 
the  vegetable  in  carbohydrates.  Even  those  vegetables 
which  are  rich  in  protein,  as  dried  peas,  beans,  and  nuts, 
are  considerably  more  difficult  of  digestion.  The  various 
disadvantages  of  meat  diet  are  met  by  like  disadvantages  of 
a  vegetable  diet.  The  physical  superiority  of  the  Ameri- 
can or  European  over  the  Hindu  or  Japanese  is  apparent, 
although  the  latter  have  progressed  enormously  since  they 
have  begun  to  eat  more  flesh.  Ferocity  is  supposed  to  re- 
sult from  meat  eating,  but  compare  the  buffalo,  rhinoceros, 
and  Chinese  pirate — all  vegetarians — with  other  animals 
for  cunning  and  ferocity.  The  vegetarian  is  less  energetic 
because  his  functions  are  less  vital.  Herbert  Spencer  had 
to  rewrite  a  book  first  written  while  he  was  on  a  vegetarian 
diet.  The  physical  strength  of  meat-eating  men  and 
animals  is  far  above  that  of  any  vegetarian  animal.  No 
vegetarian  animal  can  lift  the  weight  of  his  own  body,  but 
Louis  Cyr  lifted  over  a  ton,  and  a  lion  carrying  a  «alf  its 
own  weight  has  been  known  to  jump  a  hurdle  6  feet  high 
(Tibbies). 


42  THE   PREVENTION   OF   DISEASE 

Vegetarians  are  not  more  healthy  or  long  lived.  The 
diseases  claimed  to  be  caused  by  meat,  as  gout,  stone, 
gravel,  Bright's  disease,  hardening  of  the  arteries,  diseases 
of  animals,  ptomain  poisoning,  etc.,  are  balanced  by  dis- 
orders produced  by  too  much  starch  and  sugar,  as  indiges- 
tion, acidity,  flatulence,  obesity,  diabetes,  cholera,  dysen- 
tery (from  germs  on  raw  food),  pellagra,  and  beri-beri,  etc. 
Vegetarians  are  not  generally  so  robust,  alert,  active,  and 
energetic  as  meat  eaters,  but  are  apt  to  suffer  from  indiges- 
tion and  anemia,  and  to  have  a  poor  circulation. 

A  vegetable  diet,  with  the  addition  of  milk,  eggs,  and 
cheese,  is,  however,  a  wholly  different  matter,  and  may  be 
the  best  regimen  for  some  persons.  It  may  be  said  that 
the  well-to-do,  of  middle  age  and  over,  eat  too  much  meat 
as  a  rule.  A  single  moderate  helping  of  meat  once  daily 
is  sufficient  for  such  persons.  In  many  diseased  conditions 
and  for  the  aged  total  abstention  from  meat  for  a  time,  or 
permanently,  may  be  desirable,  but  such  a  diet  should  be 
determined  upon  individually  by  consultation  with  a 
physician.  It  is  unfortunately  true  that  much  of  the 
advice  given  by  the  average  doctor  concerning  food  rests 
largely  on  tradition  or  hearsay.  Thus,  a  leading  consult- 
ant recently  told  a  relative  of  the  writer  not  to  eat  grapes 
because  the  urine  would  be  made  more  acid.  As  we  have 
noted,  the  acid  in  fruits  is  generally  transformed  into  alka- 
line carbonates  in  the  blood  and  these  tend  to  make  the 
secretions  more  alkaline. 

Salt  is  a  most  important  constituent  of  the  tissues,  gas- 
tric juice,  and  blood,  but  enough  is  ordinarily  taken  on  and 
with  the  food. 

Water  should  be  consumed  in  abundance — 6  to  8 
glasses  daily.  It  is  better  not  to  take  too  much  water  at 
meals,  not  more  than  half  the  daily  amount,  and  the  rest 
between  meals.  Too  little  water  favors  stone  because 


HYGIENE    OF   THE    DIGESTION  43 

there  is  not  enough  water  to  dissolve  the  solids  eliminated 
by  the  kidneys.  In  the  reduction  of  obesity  water  should 
not  be  taken  at  meals,  as  water  increases  the  appetite  and 
allows  more  food  to  be  washed  down.  Only  tea,  coffee, 
and  soup  are  allowed  in  those  reducing  weight.  A  copious 
supply  of  water  is  very  essential  in  preventing  constipation. 
Water-drinking  has  been  rather  a  fad  and  therefore  over- 
done. The  drinking  of  several  quarts  of  water  daily  is 
undesirable,  as  it  causes  inaction  or  atony  of  the  stomach 
and  its  distention,  whether  the  water  be  hot  or  cold.  The 
consumption  of  ice-water  at  meals  tends  to  check  the  secre- 
tion of  gastric  juice  and  digestion. 

Water-supply. — The  importance  of  a  pure  water-supply 
is  everywhere  recognized.  Surface-water  and  bodies  of 
water  which  receive  drainage  from  the  surface  are  likely 
to  be  polluted  with  the  bowel  and  urinary  discharges  of 
men  and  animals,  which  may  give  rise  to  many  diseases, 
especially  typhoid  fever,  diarrheal  diseases,  and  intestinal 
parasites.  In  this  category  may  be  included  springs, 
rivers,  ponds,  lakes,  and  shallow  wells.  The  state  chemist 
of  Indiana  has  recently  found  (1915),  in  the  examination 
of  5000  wells  in  thickly  populated  sections,  that  over  50 
per  cent,  are  polluted,  and  he  advises  that  every  surface 
well  in  Indiana  be  abandoned.  The  discovery  of  the  germs 
normally  present  in  the  intestines  (colon  bacilli)  in  numer- 
ous small  samples  of  drinking-water  is  considered  a  sure 
sign  of  its  pollution  with  sewage.  It  is  wise  to  have  a 
domestic  water-supply  examined  by  a  competent  bacteriol- 
ogist and  chemist,  such  as  any  city  health  department 
employs.  Rain-water  is  pure  (except  for  the  dust  it 
washes  from  the  air),  and  if  the  first  washing  from  the 
roof  is  turned  away  from  the  conductors  by  an  automatic 
device,  and  if  the  cistern  is  lined  with  cement  and  is 
absolutely  tight — to  exclude  dirt,  surface-water,  and  ver- 


44  THE    PREVENTION   OF   DISEASE 

min — the  rain-water  will  remain  pure.  The  cistern- water 
should  have  an  overflow  pipe  on  the  surface  of  the  ground . 
covered  with  wire  gauze.  The  number  of  square  feet  in 
the  ground  plan  of  a  house  will  constitute  the  roof  area  for 
collection  of  rain-water.  Thus,  a  40  by  40  feet  ground 
plan  (1600  sq.  ft.)  will  give  a  roof  area  which  will  catch 
about  1000  gallons  of  water  from  1  inch  of  rainfall  (Har- 
rington). 

Driven  and  artesian  wells  usually  supply  pure  water 
because  water  from  deep  subsoil  is  ordinarily  unpolluted. 
This  is  not  always  the  case,  however,  as  fissures  in  deeply 
embedded  rocks  may  lead  polluted  water  to  great  depths. 
The  safest  surface  wells  are  those  of  brick  or  stone  lined 
throughout  with  cement,  and  covered  so  tightly  that 
surface-water  and  vermin  are  excluded.  They  may  be- 
come polluted  from  drainage  into  the  deeper  layers  of  the 
subsoil  from  cesspools  and  privies. 

Boiling  water  for  fifteen  minutes  is  the  simplest  method 
of  purification.  To  restore  its  normal  taste  it  should  be 
poured  from  one  vessel  to  another,  to  mix  it  with  air, 
after  it  has  been  boiled.  Most  filters  are  useless  in  remov- 
ing germs.  The  Chamberland-Pasteur  filter,  made  of 
unglazed  earthenware,  through  which  the  water  must 
slowly  find  its  way,  is  the  only  filter  which  prevents  dis- 
ease germs  from  passing.  It  must,  however,  be  scrubbed 
and  boiled  ten  minutes  twice  a  week  (Harrington).  It 
is  fastened  to  the  water  faucet.  Chlorid  of  lime,  or  bleach- 
ing powder,  is  a  safe  agent  to  use  for  sterilizing  water, 
since  it  does  not  impart  much  taste  or  odor  and  is  perfectly 
harmless  in  the  amount  used.  Six  hundred  cities  in  this 
country  and  Canada  use  it  to  purify  their  public  water- 
supplies.  One  teaspoonful  of  the  following  chlorid  of  lime 
solution  is  added  to  2  gallons  of  water,  which  should 
then  stand  fifteen  minutes  or  more  before  it  is  fit  to  drink. 


HYGIENE    OF   THE    DIGESTION  45 

The  solution  itself  is  made  by  dissolving  1  teaspoonful 
of  fresh  chlorid  of  lime  in  1  quart  of  water,  keeping  it 
tightly  sealed  in  a  Mason  fruit  jar. 

Ice. — To  avoid  dangers  from  ice  composed  of  impure 
water,  containing  possibly  the  germs  of  typhoid  fever, 
diarrhea,  and  dysentery,  one  should  always  use  clear  ice 
which  is  made  from  pure  water  or  water  from  which  the 
germs  have  settled  out.  Clear  ice  is  safe  ice.  If  ice  con- 
tains germs  it  is  rarely  absolutely  transparent.  One  should 
avoid  ice-water  in  public  places  when  the  ice  is  floating 
in  the  water.  Water  should  be  cooled  by  surrounding  it 
with  ice  which  does  not  come  in  direct  contact  with  the 
water.  The  reason  for  this  is  that  ice  may  often  be 
handled  by  persons  with  hands  soiled  with  their  own 
excretions,  and  thus  may  be  a  means  of  transmission 
of  typhoid  fever,  diarrheal  diseases,  and  intestinal 
parasites. 

One  would  certainly  not  drink  water  in  which  such  per- 
sons as  servants  and  railway  employees  had  dipped  their 
hands,  yet  one  does  it  every  day  unwittingly,  in  the  form 
of  melted  ice. 

The  fashion  of  late  dinner  is  based  on  the  fact  that  leisure 
at  this  time  favors  digestion,  in  that  blood  is  not  drawn 
away  from  the  stomach  for  mental  or  physical  labor.  A 
heavy  meal  in  the  middle  of  the  day  conduces  to  inactivity 
in  mental  workers.  In  the  case  of  children  and  elderly 
persons  it  is  often  best  that  the  heartiest  meals  be  breakfast 
and  at  midday  and  the  lightest  in  the  evening.  Candy, 
ices,  and  sweets  of  all  kinds  are  the  bane  of  children's 
digestion  and  health.  Sometimes  only  the  discipline  and 
isolation  of  boarding-schools  will  prevent  this  dissipation. 
The  proper  standing  position  is  requisite  for  good  digestion 
and  this  is  considered  under  Digestive  Disorders.  Corsets 
constricting  the  wais-t  displace  the  stomach  downward 


46  THE   PREVENTION   OF  DISEASE 

and  interfere  with  digestion.     The  straight-front  corset, 
loose  above,  is  the  best  type. 

In  order  to  calculate  an  economic  and  sufficient  diet 
scientifically  all  articles  of  digestible  food  consumed  each 
day  are  reckoned  in  terms  of  heat  value;  that  is,  the  value 
of  food  is  considered  to  lie  in  the  amount  of  heat  it  will 
produce  in  burning  outside  the  body.  This  follows  be- 
cause food  undergoes  what  is  practically  combustion  within 
the  body.  The  unit  of  food  value  or  calory  is  that  amount 
of  heat  required  to  raise  1  kilogram  (about  1  quart)  of 
water  from  0°  to  1°  C.  The  daily  food  requirements  for 
adults  vary,  according  to  different  authorities,  from  2500 
to  3000  calories,  containing  from  100  to  130  grams  of 
protein,  50  to  100  grams  of  fat,  and  250  to  500  grams  of 
carbohydrates.  Fat  and  carbohydrates  are  more  or  less 
interchangeable,  fat,  however,  producing  2j  times  more 
heat  than  an  equal  weight  of  starch  or  sugar  (carbohy- 
drates). It  is  now  customary  to  give  the  heat  or  calory 
value  of  food  per  ounce  in  tables  showing  the  composition 
of  food.  Take  milk,  for  instance,  the  heat  value  is  equal 
to  20  calories  for  each  ounce,  or  640  per  quart.  Four 
quarts  of  milk  would  be  required  to  afford  the  daily  2500 
calory  food  requirement. 


CHAPTER  III 

PERSONAL  HYGIENE  (Continued) 

Exercise:  Special  Exercises  for  Different  Ages,  Rationale  of 
Exercise.  Clothing.  Baths :  Outdoor  Bathing,  Lukewarm,  Warm, 
Hot,  Turkish,  and  Cabinet  Baths.  Ventilation:  The  Complexion: 
Sunburn,  Freckles,  and  Acne.  Care  of  the  Hair:  Baldness  and 
Dandruff.  Care  of  the  Finger-  and  Toe-nails. 

EXERCISE 

Special  Exercises  for  Different  Ages. — From  infancy  up 
to  the  seventh  year  muscular  movements  are  not  precise 
nor  finely  co-ordinated.  The  nervous  and  muscular  sys- 
tems are  not  sufficiently  developed  for  the  performance  of 
accurate  and  co-ordinate  movements. 

Thus,  the  baby  begins  kicking  and  moving  the  hands 
and  legs;  then  picking  up  and  dropping  things;  playing  with 
blocks  and  digging  and  piling  dirt  or  sand  come  next,  and 
later  running,  throwing,  cutting  and  folding,  and  the  use 
of  bows,  slings,  and  the  knife.  From  seven  to  twelve 
the  outer  (cortical)  areas  of  the  brain,  which  control 
motion  and  sensation,  are  chiefly  developed,  and  finer  and 
more  complicated  movements  after  this  time  are  possible. 
Simple  ball  games,  hide  and  seek,  tag,  leap-frog,  marbles, 
baseball,  football,  swimming,  riding,  bicycling,  wrestling, 
and  fishing  begin  in  this  period.  Subsequent  to  this  age 
the  highest  functions  of  the  brain  develop,  as  self-control, 
association  of  ideas,  and  judgment.  It  is  at  about  twelve 
that  the  ability  for  team  play  begins,  and  this  mental  plane 
is  equivalent  to  that  of  the  savage. 

47 


48  THE   PREVENTION   OF   DISEASE 

After  twelve  exercises  requiring  precision  and  accuracy 
may  be  undertaken,  as  manual  training,  playing  musical 
instruments,  baseball,  cricket,  fencing,  tennis,  boxing, 
bowling,  etc.  The  heart  is  not  equal  to  long-sustained 
competitive  athletics  at  this  age,  particularly  long  distance 
running.  The  heart  gives  out  by  becoming  dilated  and 
only  short  distance  competitive  running  should  be  allowed 
until  boys  are  eighteen.  School  and  college  athletics  tend 
toward  special  and  excessive  development  of  the  select  few 
in  competitive  sports,  whereas  the  ideal  training  consists 
in  general  physical  development  of  all.  To  bring  this 
about  in  youth  there  should  be  three  half-hours  weekly 
given  to  gymnasium  class  exercises,  together  with  outdoor 
sports  and  walking.  The  special  objects  should  be  to 
overcome  by  appropriate  exercises  any  special  inherent 
physical  weaknesses  or  shortcomings  (either  under-  or  over- 
development of  parts) ,  and  to  produce  a  fine  general  bodily 
development,  and  to  bring  out  those  special  qualities  so 
essential  for  any  successful  career — energy,  alertness, 
strength,  courage,  and  endurance.  A  youth  should  walk 
when  he  may  ride,  run  when  he  may  walk,  and  climb  when 
he  may  be  lifted  (elevator) .  All  the  athletic  outdoor  sports 
should  be  his — skating,  rowing,  swimming,  hunting,  and 
fishing.  Dancing  is  not  to  be  despised. 

The  various  systems  of  home  exercises  by  correspondence 
have  advantages  and  disadvantages.  They  are  very  apt 
not  to  be  kept  up,  as  they  are  not  sufficiently  agreeable, 
being  taken  as  a  duty  rather  than  pleasure.  They  resemble 
the  use  of  the  axe  for  exercise,  which  fond  parents  are  apt 
to  urge  on  their  sons  who  are  bursting  for  sport. 

These  home  exercises  usually  consist  in  developing 
certain  muscles  by  bringing  into  play  the  action  of  opposing 
muscles.  This  means  the  resistance  of  the  action  of  one 
group  of  muscles  by  an  opposing  group.  For  example, 


EXERCISE  49 

one  has  to  concentrate  the  mind  strongly  upon  bending  the 
arm  at  the  elbow,  while  at  the  same  time  making  this 
movement  difficult  by  contraction  of  the  muscles  opposing 
this  action.  By  going  through  such  exercises  conscien- 
tiously for  twenty  minutes  each  morning  on  rising,  and 
following  them  by  a  shower  and  vigorous  rub  with  a  coarse 
towel,  one  may  greatly  increase  the  muscular  strength. 
But  this  training  has  the  tendency  to  make  one  "muscle 
bound"  and  not  fit  for  skilled  sports,  where  accuracy  of 
movement,  quickness,  alertness,  suppleness,  and  grace  are 
desirable,  as  in  tennis. 

The  expense  and  secrecy  attending  the  taking  of  such 
systems  of  physical  exercise  add  to  their  allurement,  and 
they  are  doubtless  better  than  no  exercise  at  all,  although 
they  do  not  favor  all-round  development,  as  do  many 
outdoor  sports.  The  systems  which  consist  of  bending  of 
the  body  and  movements  of  the  limbs  are  more  suitable  for 
the  mature  business  man  who  wishes  to  exercise  at  home 
without  apparatus.  ("Ten  Minutes'  Exercise  for  the 
Busy  Man,"  Dr.  L.  H.  Gulick;  "Fifteen  Minutes  Invested 
Daily  for  Health's  Sake,"  W.  J.  Cromie.)  Walking  is  the 
cheapest  and  easiest  form  of  exercise  for  those  in  middle 
life  or  beyond.  Walking  should  be  done  at  a  brisk  pace, 
and  one  should  not  brood  over  one's  self  or  one's  troubles, 
as  mental  relaxation  is  as  important  as  exercise.  This  is 
the  advantage  of  golf,  as  it  is  almost  impossible  to  think 
of  other  things  when  devoted  to  this  engrossing  game.  In 
walking  one  should  "go  about  admirin'  'ow  the  world  was 
made."  When  one  is  greatly  taxed  by  mental  work  it  is 
bad  to  burn  the  candle  at  both  ends  by  trying  to  exercise 
at  the  same  time.  In  such  cases  rest  may  be  found 
essential.  Muscular  fatigue  also  generates  chemical  sub- 
stances which  may  act  as  poison  to  the  blood-vessels  and 
induce  arteriosclerosis,  which  is  so  synonymous  with  old 

4 


50  THE   PREVENTION   OF  DISEASE 

age.  One  should  feel  refreshed  after  exercise,  and  not  the 
reverse. 

The  special  exercises  and  sports  suitable  for  the  middle 
aged  and  elderly  include  golf,  bicycle  riding  (without  hill 
climbing),  walking,  horseback  riding,  bowling,  hunting, 
fishing,  and  gardening.  Violent  exercises  of  all  kinds  are 
undesirable  and  often  dangerous,  such  as  boxing,  fencing, 
mountain  climbing,  tennis  and  handball,  running,  rowing, 
basket-ball,  and  long  distance  swimming.  The  rules  for 
middle  age  should  be  the  reverse  of  those  for  youth.  One 
should  not  take  any  unnecessary  violent  exertion,  one 
should  walk  rather  than  run,  and  not  lift  heavy  weights,  as 
a  trunk  or  articles  of  furniture.  For  the  elderly  the  most 
suitable  exercises  are  walking,  riding  or  motoring,  and 
billiard  playing.  Of  course,  it  makes  a  great  difference 
whether  one  has  kept  in  good  muscular  training  from  youth 
onward,  and  such  may  take  much  more  strenuous  exercise 
than  individuals  not  accustomed  to  physical  exercise. 
Our  famous  Secretary  of  State,  Mr.  Richard  Olney,  was  an 
expert  tennis  player  well  into  his  sixties. 

Rationale  of  Exercise. — Exercise  or  muscular  movements 
depend  upon  three  factors — a  normal  nerve  impulse,  con- 
traction of  the  muscle,  and  an  efficient  supply  of  fuel.  It 
is  not  sufficiently  appreciated  that  complicated  movements, 
such  as  are  required  by  the  simplest  actions  in  life,  are  as 
much  nervous  as  muscular,  and  by  them  the  brain  and 
nervous  system  are  developed  as  well  as  the  muscles.  In 
the  performance  of  muscular  movements  there  are  to  be 
considered  the  origination  of  an  impulse  in  the  motor  area 
of  the  outer  part  (cortex)  of  the  brain,  its  conduction  along 
the  spinal  cord  and  thence  along  a  motor  nerve,  and  the 
answering  contraction  of  the  muscle. 

In  voluntary  movements  the  impulse  travels  from  the 
brain  at  the  rate  of  about  two  miles  a  minute.  Automatic 


EXERCISE  51 

movements  are  those  occurring  when  impulses  are  sent 
from  the  central  nervous  system  without  any  conscious 
knowledge,  as  in  the  case  of  the  beating  of  the  heart  and  the 
movements  of  the  stomach  and  bowels.  Reflex  action 
takes  place  when  the  end  of  a  sensory  nerve  is  stimulated 
and  the  impulse  is  carried  along  it  to  the  spinal  cord  or 
brain,  and  is  transformed  by  the  nervous  center  into  an 
impulse  traveling  back  along  a  motor  nerve  to  a  muscle — 
resulting  in  its  action.  Reflex  movements  may  occur  in 
sleep  and  unconsciousness,  and  even  when  opposed  by  the 
will,  as  in  the  case  of  winking  when  the  eyeball  is  touched. 

The  fuel  required  for  muscular  action  is  chiefly  derived 
from  the  starches  and  sugars  of  food.  These  are  burned 
in  the  muscles  in  the  form  of  a  kind  of  sugar  (glycogen)  by 
means  of  the  oxygen  brought  in  the  blood  from  the  lungs. 
Thus  heat  and  energy  are  produced.  Sugar  is,  therefore, 
one  of  the  best  stimulants  to  muscular  action  and  is  fed 
soldiers  on  the  march,  often  as  chocolate,  rich  in  both  sugar 
and  fat.  Meat  and  fat  may  replace  sugar  and  starches 
when  they  are  absent  from  the  food. 

Muscular  fatigue  is  due  to  three  factors — it  is  caused 
by  nervous  exhaustion,  by  the  chemical  waste-products  of 
muscular  contraction  (chiefly  lactic  acid),  and  by  consump- 
tion of  the  fuel  which  supplies  muscular  contraction.  The 
nervous  element  in  fatigue  has  been  found  by  Crile  to 
depend  upon  actual  changes  in  the  brain,  seen  micro- 
scopically after  overuse  of  the  muscles  in  animals.  This 
fact  enforces  the  necessity  of  a  normal  nervous  system  for 
the  successful  accomplishment  of  physical  exercise.  The 
converse  is  seen  in  the  absolute  loss  of  muscular  power  in 
nervous  prostration,  so  that  even  talking  or  lifting  an  arm 
become  a  great  exertion. 

The  use  of  all  drugs  tending  to  impair  the  nervous 
system,  particularly  tobacco  and  alcohol,  are,  therefore, 


52  THE   PREVENTION    OF   DISEASE 

essentially  inimical  to  the  best  performance  of  any  athletic 
feats  requiring  endurance  and  the  most  harmonious  action 
of  various  groups  of  muscles. 

Muscular  and  nervous  development  through  exercise, 
therefore,  go  hand  in  hand.  The  muscles  themselves 
enlarge  through  increase  in  muscle  cells  and  grow  stronger 
because  more  of  their  fibers  come  under  the  control  of  the 
nerves,  and  because  the  nervous  impulses  become  more 
intense.  The  rapidity  of  transmission  of  the  nervous 
impulse  from  the  brain  along  the  nerve  is  also  increased. 

Occasionally  fibers  of  muscles  break  during  severe  exer- 
cise, and  sore  spots  and  occasionally  lumps  form  in  the 
muscle  and  persist  for  several  weeks.  In  the  parlance  of 
the  trainer  this  is  called  "charley horse." 

*The  effect  of  exercise  upon  the  breathing  and  heart  are 
most  important.  During  violent  muscular  exertion  more 
blood  must  be  carried  to  the  lungs  in  order  that  the  in- 
crease of  waste-products  from  the  muscles  (carbonic  acid 
gas)  may  be  there  gotten  rid  of  and  replaced  by  oxygen, 
which  is  needed  in  excess  in  the  muscles  to  burn  the  fuel. 
At  first  the  breathing  becomes  violent,  rapid,  and  shallow, 
and  dizziness  and  even  unconsciousness  may  ensue — in 
running  for  instance.  Usually  one  gets  his  "second  wind" 
in  about  three  minutes,  which  means  that  the  breathing  has 
become  deeper  and  more  powerful,  that  more  oxygen  is 
taken  in  and  more  carbonic  acid  gas  exhaled,  and  that  the 
action  of  the  heart  is  stronger.  This  forced  breathing  is 
brought  about  automatically  by  increase  of  carbonic  acid 
gas  in  the  blood,  which  stimulates  the  center  of  breathing 
situated  at  the  base  of  the  brain. 

Since  violent  exercise  demands  a  greater  supply  of 
blood  in  the  lungs,  heart,  and  muscles,  the  heart  responds 
by  more  rapid  and  stronger  contractions.  These  later 
become  slower  and  more  effective,  since  the  heart  dilates 


EXERCISE  53 

to  hold  more  blood  and,  therefore,  more  may  be  forced  out 
at  each  contraction.  Exercise  excites  reflexly  centers  in 
the  brain  that  stimulate  the  heart's  action,  while  the 
distention  of  the  cavities  of  the  heart  with  more  blood 
and  the  increased  heat  of  the  blood  in  exercise  both 
stimulate  the  heart.  In  a  man  in  athletic  condition  the 
normal  pulse  of  70  may  increase  to  130  or  even  190  beats 
per  minute  during  sudden  and  violent  exertion,  but  soon 
returns  to  normal.  In  the  man  out  of  condition  the  pulse 
may  remain  high  and  somewhat  irregular  for  some  time 
after  severe  exercise.  During  the  exertion  of  rising  sud- 
denly from  a  lying  to  standing  position,  in  the  normal  indi- 
vidual, the  heart  is  naturally  quickened  by  some  12  beats 
to  the  minute,  and  if  it  increases  by  as  much  as  20  beats 
it  is  a  sign  of  poor  physical  condition.  Again,  in  rising 
suddenly  the  blood  tends  to  leave  the  brain  and  collect  in 
the  muscles  of  the  lower  extremities.  The  normal  tone  of 
the  vessels  and  heart  tend  to  prevent  this.  If  the  blood- 
pressure  is  taken  before  rising  and  immediately  after 
rising  from  a  horizontal  to  an  erect  position,  in  the  arm  of 
an  individual  with  poor  tone  of  vessels  and  heart,  the  pulse 
will  be  quickened  more  than  10  beats  and  the  blood-press- 
ure will  fall  in  the  arm  after  rising.  In  the  highest  physical 
condition  the  blood-pressure  is  increased  in  standing,  ow- 
ing to  an  immediate,  compensatory,  heightened  tone  of  the 
vessels  and  heart,  and  the  pulse  is  augmented  but  a  few 
beats. 

Thus,  Crampton  has  introduced  a  scale  to  test  the 
physical  condition  by  estimating  the  blood-pressure  and 
pulse-rate  of  an  individual  lying  and  standing.  A  person 
getting  100  per  cent,  would  have  a  rise  of  10  in  blood-press- 
ure and  only  4  in  pulse-rate.  If  the  blood-pressure  falls 
when  one  rises  into  an  erect  position,  this  occurrence  leads 
to  increased  rapidity  of  the  heart  in  its  natural  endeavor 


54  THE   PREVENTION   OF  DISEASE 

to  fill  the  vessels.  Crampton's  test  is  still  svbjudice.  But 
unquestionably  a  quick  return  of  a  rapid  pulse  to  normal 
after  exertion  is  a  most  reliable  sign  of  a  good  physical 
condition. 

In  former  times  it  is  reported  that  short  operations  were 
performed  on  persons  painlessly  by  having  two  strong 
men  lift  the  patient  suddenly  from  a  horizontal  to  the  erect 
position.  Partial  unconsciousness  or  faintness  followed, 
owing  to  the  blood  leaving  the  brain  during  this  procedure. 

Dangers. — The  chief  danger  in  sound  persons  from 
sudden  violent  exercise,  especially  when  they  are  not  in 
training,  is  acute  dilatation  of  the  heart.  This  also  occurs 
in  athletes  in  running,  rowing,  football,  etc.,  but  in  them 
the  heart  usually  returns  to  normal  within  a  few  hours  or 
days.  As  we  have  said,  in  getting  "second  wind"  and  in  all 
violent  exertion  the  heart  dilates  somewhat,  but  it  is  exces- 
sive dilatation  of  which  we  speak.  This  is  shown  by 
blueness  of  the  face,  bleeding  nose,  breathlessness,  and 
dizziness.  In  .those  not  in  training,  especially  under  fif- 
teen and  over  thirty,  the  dilatation  may  persist  for  a  long 
time  or  always,  and  a  weak  heart  result.  This  sometimes 
occurs  in  elderly  persons  when  mountain  climbing  after 
leading  a  sedentary  life. 

In  young  children  the  volume  of  the  heart  is  proportion- 
ately much  smaller  to  the  diameter  of  the  vessels  than  it 
becomes  later,  for  during  adolescence  the  volume  of  the 
heart  increases  enormously  (twelvefold)  and  the  diameter 
of  the  arteries  only  threefold  (Benke).  So  that  overexer- 
tion  in  children,  up  to  the  age  of  fifteen  and  over,  causes 
great  strain  on  a  heart  which  is  not  fully  developed  in  size 
or  strength,  but  especially  in  size.  In  an  experiment  on 
40  lx)ys,  from  seven  to  fourteen,  Riviere  found  that  after 
a  walking  excursion  which  lasted  a  week,  in  which  the 
boys  walked  five  to  seven  miles  daily,  there  was  dilatation 


EXERCISE  55 

of  the  heart  still  persisting  two  and  one-half  months  in  10 
of  the  younger  boys,  and  it  seemed  probable  that  from 
one  to  two  years  would  be  required  before  their  complete 
recovery  (McKenzie). 

Any  sudden  and  violent  effort,  as  in  lifting,  wrestling, 
and  running,  greatly  increases  the  blood-pressure  momen- 
tarily (from  the  normal,  109,  to  210  in  McCurdy's  tests), 
and  this  may  lead  to  rupture  of  an  artery  in  the  middle 
aged  and  elderly,  though  never  in  a  sound  young  person. 
In  more  moderate  continuous  exertion  requiring  endurance 
the  blood-pressure  rises,  though  not  to  so  high  a  point,  but 
falls  rapidly  and  below  normal  in  the  sound  individual. 
The  pulse-rate  increases  more  markedly  and  does  not  return 
to  normal  nearly  so  soon.  Thus,  in  bicycling  for  half  an 
hour  Bowen  found  that  the  blood-pressure  increased  from 
140  to  190  at  the  end  of  this  time,  and  the  pulse  from  72  to 
132.  Within  ten  minutes  after  completion  of  the  ride  the 
blood-pressure  fell  to  130  and  the  pulse  to  102,  but  only 
after  another  half-hour  did  the  pulse  become  normal  (72). 

The  best  exercises  are  those  bringing  into  action  large 
groups  of  muscles  and  developing  the  body  as  a  whole. 
When  a  muscle  contracts  it  squeezes  the  blood  out  of  its 
veins,  and  at  the  same  time  in  shortening  it  widens  and 
allows  more  blood  to  flow  through  the  arteries,  so  that 
three  times  more  blood  is  supplied  to  a  muscle  during 
exercise  than  at  rest.  Indeed,  the  muscles  are  veritable 
hearts.  The  heart  gets  its  own  blood  supply,  both  during 
contraction  and  in  the  rest  periods,  and  when  it  beats 
violently  during  general  exercise  it  is  supplied  with  more 
blood  than  usual  and  develops  accordingly,  like  any  other 
muscle.  General  exercises  developing  large  groups  of 
muscles  and  the  vital  organs — the  heart  and  lungs — in- 
clude running,  swimming,  rowing,  skating,  wrestling, 
boxing,  riding,  fencing,  and  dancing.  These  are  the  chief 


56  THE    PREVENTION    OF   DISEASE 

developmental  exercises  and  differ  from  special  exercises 
which  develop  small  groups  of  muscles.  It  is  especially  in 
youth  and  after  middle  age  that  care  must  be  taken  to 
avoid  severe,  sudden,  or  prolonged  exertion. 

CLOTHING 

We  can  hope  to  exert  but  little  influence  upon  the  fair 
sex  in  the  matter  of  clothing,  since  fashion  is  the  sole 
dictator  of  dress  in  most  instances. 

One  not  rarely  sees  a  wonderful  combination  of  such 
material  as  a  sort  of  refined  mosquito  netting  and  fur  in 
the  composition  of  an  outer  garment,  and  it  is  not  unusual 
to  observe  the  distribution  of  fur  over  remarkable  portions 
of  the  anatomy,  the  remaining  parts  having  little  or  no 
covering  whatever.  Then  at  another  time  fashion  may 
demand  a  wholly  different  anatomic  arrangement  of  the 
furs  without  regard  to  weather  or  season.  In  attempting 
to  remonstrate  with  patients,  the  doctor  is  either  met  with 
fallacious  arguments,  on  the  one  hand,  or  demure  accept- 
ance on  the  other,  without  any  endeavor,  however,  on  the 
part  of  the  patient  to  put  the  advice  into  use.  In  the 
matter  of  night  garments  the  physician  is  equally  futile. 
The  total  exposure  of  the  upper  part  of  the  body  is  not  con- 
ducive to  avoidance  of  rheumatic  or  catarrhal  affections 
of  this  region,  or  to  their  recovery. 

In  underclothing  the  two  qualities  of  most  importance 
are  those  of  retaining  heat  and  absorbing  perspiration. 
Wool  is  pre-eminently  the  best  non-conductor  and,  there- 
fore, prevents  the  bodily  warmth  from  escaping.  Many 
persons  think  they  cannot  wear  wool  because  it  causes 
too  much  irritation  of  the  skin.  Marino,  or  mixtures  of 
wool  and  cotton,  may  be  used,  or  materials  made  with 
cotton  on  one  side  and  wool  on  the  other. 

Wool  also  absorbs  perspiration  readily  and  evaporates  it 


CLOTHING  57 

slowly  and  is  the  best  material  for  underwear  the  year 
round.  Wool  shrinks  and  becomes  matted  or  felted  by 
frequent  washing;  but  this  trouble  may  be  averted  to  a 
considerable  extent  by  washing  in  tepid  water  with  fre- 
quent rinsing,  but  avoiding  forcible  wringing  or  rubbing. 
Cotton  clothing  is  now  worn  by  many  indoor  workers  the 
year  round.  The  fabric  does  not  naturally  absorb  moisture 
so  readily  and  cools  the  body  more  than  wool  when  wet, 
nor  does  it  retain  heat  as  well  as  wool  or  fur,  which  contain 
so  many  air  spaces  that  act  as  non-conductors.  Yet  cotton 
is  woven  loosely  in  such  a  way  as  to  serve  as  a  good  sub- 
stitute for  wool  in  those  not  exposed  to  cold,  wet,  or  drench- 
ing sweat.  Linen  is  about  on  a  par  with  cotton  in  absorb- 
ing moisture  and  retaining  body  heat.  Linen  garments  are 
more  expensive,  but  will  stand  more  washing.  The  linen 
mesh  is  particularly  appropriate  for  the  tropics  and  hot 
weather  in  imparting  a  sense  of  coolness.  Silk  underwear 
is  expensive  and  shrinks  in  washing,  but  absorbs  perspira- 
tion readily,  and  is  cool  and  pleasant  for  summer  use. 
Impermeable  materials,  as  rubber,  mackintosh,  and  leather, 
are  chiefly  of  value  for  outer  garments  in  protection  against 
wind  and  wet.  They  retain  the  moisture  of  the  body,  and 
so  are  unsuitable  for  wear  next  the  skin,  or  even  as  outer 
covering  when  one  is  taking  violent  exercise.  Brightly 
dyed  underwear  and  stockings  are  undesirable,  as  the 
anilin  colors  irritate  the  skin  and  produce  eruptions.  If 
the  feet  perspire  freely  the  stockings  should  be  changed 
often  so  as  to  be  clean.  By  first  soaking  the  feet  in  hot 
water,  and  then  drying  them  and  dusting  on  a  mixture  of 
salicylic  acid  (1  part)  and  starch  (3  parts)  the  perspiration 
will  be  much  reduced.  The  same  treatment  is  useful  in 
troublesome  sweating  of  the  hands  or  armpits  and  to 
prevent  its  attendant  bad  odor.  If  the  clothing  is  damp 
the  growth  of  bacteria  and  parasites  of  skin  diseases  is 


58  THE   PREVENTION    OF   DISEASE 

favored,  so  when  perspiring  freely  the  underclothes  should 
be  changed  and  put  into  the  wash  or  well  aired  and  dried 
before  wearing  them  again.  White  cotton  or  linen  outer 
garments  are  worn  in  the  tropics  because  dark  colors 
absorb  heat  rays  of  the  sun  more  readily  and  because 
cotton  or  linen  do  not  retain  bodily  heat  like  wool. 
Many  persons  wear  too  heavy  underclothing  in  winter. 
For  those  exposed  to  severe  outdoor  weather  in  their  busi- 
ness thick  underclothing  may  be  essential,  but  is  apt  to 
make  indoor  workers  sensitive  to  cold  and  subject  to  colds. 

The  more  sensible  way  is  to  wear  but  little  heavier  under- 
clothing in  the  house  in  winter  than  in  summer,  and  to 
dress  very  warmly  in  ulsters,  furs,  etc.,  when  going  out 
into  the  cold. 

Hats  should  not  be  made  to  fit  the  head  exactly,  as  they 
are  not  comfortable  and  do  not  afford  proper  ventilation. 
The  shape  of  shoes  most  desirable  is  of  importance  and  is 
discussed  in  another  place  (page  328) . 

BATHS 

Baths  are  not  by  any  means  of  use  solely  for  cleansing 
purposes.  A  cold  plunge  is  not  particularly  cleansing, 
yet  has  a  marked  influence  upon  the  body.  A  daily  cold 
bath  (50°  to  70°  F.)  tends  to  render  the  skin  less  sensitive 
to  cold,  and  so  prevents  colds,  and  has  a  pronounced  stimu- 
lating effect  upon  the  circulation,  respiration,  and  nervous 
system.  This  action  is  seen  when  cold  water  is  dashed 
upon  the  face  and  chest  in  fainting,  or  in  failing  respiration, 
and  is  relied  upon  to  resuscitate  newborn  infants,  when 
they  fail  to  breathe,  and  to  restore  persons  in  a  fainting 
condition.  The  cold  bath  is  customary  among  the  better 
class  of  English  and  Americans,  and  the  ruddiness,  ro- 
bustness, and  fine  complexions  of  our  insular  cousins  may 
be  due  in  no  small  measure  to  this  habit. 


BATHS  59 

A  daily  cold  bath  should  be  taken  by  all  healthy  youths 
and  adults  under  middle  age  if  they  are  able  to  secure  the 
reaction  or  warm  after-glow  which  should  succeed  the 
bath.  The  bath  should  be  taken  in  a  warm  room,  to  favor 
reaction,  and  be  followed  by  vigorous  rubbing  with  a 
coarse  (linen  mesh  is  best)  towel.  In  case  a  person 
suffers  from  chilliness  after  the  bath  it  may  often  be  obvi- 
ated by  standing  or  sitting  in  hot  water  while  cold  water 
is  used  by  sponging  or  by  a  shower.  Cold  sponging  with 
salt  and  water  while  standing  in  warm  water  is  a  good 
method  for  delicate  children  when  followed  by  brisk  rub- 
bing with  a  coarse  towel. 

Persons  not  habituated  to  cold  baths  should  begin  them 
in  summer,  and  then  may  continue  them  through  the  winter 
months  without  discomfort.  In  taking  cold  baths,  plunges, 
or  showers  the  water  should  not  come  in  contact  with  the 
body  more  than  a  minute  or  two.  Cold  baths  are  undesir- 
able and  often  harmful  for  young  children,  persons  with 
kidney  disease  or  hardening  of  the  arteries;  or  elderly  indi- 
viduals, unless  they  have  been  habituated  to  them  all 
their  lives.  Also  cold  baths  are  inadvisable  for  women 
during  menstruation  and  in  the  later  months  of  pregnancy, 
and  for  both  sexes  when  much  fatigued  or  very  hot  after 
exercise.  A  cold  plunge  is  not  injurious,  however,  for 
healthy  persons  perspiring  mildly  after  moderate  exercise. 

Outdoor  Bathing.— Sea-bathing  (60°  to  75°  F.)  has  the 
beneficial  action  of  the  cold  bath  plus  the  salubrious  effects 
of  one  of  the  best  forms  of  exercise  in  the  fresh  air,  the 
stimulating  influence  of  the  waves  and  salt  upon  the  skin, 
and  the  pleasure  and  sunlight.  The  temperature  range  is 
considerable,  and  the  proper  duration  of  the  bath  depends 
upon  this — anywhere  from  two  to  twenty  minutes.  Two 
minutes  is  too  long  in  many  parts  of  the  Northern  New 
England  and  Pacific  coasts,  whereas  twenty  minutes  is 


60  THE    PREVENTION    OF   DISEASE 

almost  too  short  in  the  shallow  and  warm  waters  of  Cape 
Cod  and  the  middle  and  southern  Atlantic  shores  of  the 
United  States,  where  the  water  reaches  a  temperature  of 
72°  to  75°  F.  or  more.  There  is  great  harm  done  children 
and  delicate  persons  through  a  prolonged  stay  in  cold 
water.  A  warm  reaction  should  follow  sea-bathing,  as 
after  the  cold  bath  indoors.  One  so  frequently  sees  persons 
blue  and  shivering  loitering  about  on  the  shore  or  knee-deep 
in  cold  water  instead  of  taking  a  plunge  and  then  out. 
There  is  immense  loss  of  heat  and  combustion  of  food  or 
tissue  in  the  body  to  supply  this.  The  result  is  a  great 
drain  upon  the  vitality,  exhaustion,  and  often  loss  of 
weight  after  a  prolonged  course  of  cold  sea-bathing.  Cold 
water  has  a  njore  powerful  influence  in  reducing  the  tem- 
perature of  the  body  than  any  other  means  known,  hence 
its  use  in  fevers  and  sunstroke. 

Especially  pernicious  is  the  habit  children  have  of  play- 
ing out  of  the  water  in  wet  bathing  suits  (thus  cooling  the 
body  by  evaporation) ,  and  then  returning  into  the  water, 
or  of  wading  in  cold  water  while  their  bare  heads  are 
exposed  to  the  burning  sun — a  most  favorable  procedure 
for  sunstroke.  To  stay  in  cold  water  long  one  must  be 
stout,  since  the  layer  of  fat  under  the  skin  acts  as  a  non- 
conductor, keeping  heat  in  and  cold  out.  Women  have 
more  subcutaneous  fat  than  men,  and  their  greater  ability 
to  stand  around  in  cold  water,  as  compared  to  males,  is 
notorious.  Long-distance  swimmers  must  be  fat  to  with- 
stand the  cold  and  exhaustion. 

It  is  always  wise  to  wet  the  head  before  entering  cold 
water,  and  it  is  unwise  to  bathe  when  excessively  hot,  but 
it  is  safer  when  moderately  warm  from  exercise  than  when 
beginning  to  cool  off.  It  is  the  custom  not  to  bathe  until 
three  hours  after  meals,  because  the  action  of  cold  water 
alters  the  distribution  of  the  blood  to  the  digestive  organs 


BATHS  61 

and  other  parts  of  the  body.  From  bathing  soon  after  eat- 
ing persons  have  suffered  from  nausea,  vomiting,  cramps 
in  their  bowels,  and  even  death. 

Cold  applied  to  the  skin  drives  the  blood  into  the  inter- 
nal organs  and  to  the  head  by  contraction  of  the  external 
blood-vessels.  This  is  the  reason  for  first  wetting  the 
head.  To  those  used  to  cold  baths  sea-bathing  may 
be  indulged  in  before  breakfast.  The  rule  in  all  cases 
should  be  never  to  stay  in  water  until  one  has  blue  fingers 
and  lips  and  is  shivering  and  chattering  with  cold,  for  one 
should  always  feel  warm  after  the  bath. 

Sudden  and  unexpected  deaths  occur  in  swimmers  and 
bathers  from  fainting,  overexertion,  and  cramps.  Swim- 
ming is  tremendous  exercise,  since  it  brings  into  play 
most  of  the  muscles  in  the  body.  If  one  is  swimming  at 
top  speed  and  in  rough  water  the  strain  is  extreme  on  even 
the  healthy  heart.  The  writer  watched  a  professional 
athlete  in  pink  of  condition  give  out  through  making 
extraordinary  efforts  in  swimming  to  catch  a  drifting  boat. 
Seeing  a  sudden  pallor  come  overfiis  face,  the  swimmer  was 
rescued  just  in  time.  If  the  heart  is  naturally  weak  the 
exertion  of  swimming  may  easily  cause  it  to  fail.  Some- 
times a  weak  heart  will  momentarily  stop  when  a  person 
jumps  into  cold  water.  The  author  has  known  this  to  hap- 
pen twice  in  the  case  of  a  patient  jumping  into  a  swimming 
pool.  Drowning  will  result  unless  help  is  directly  at  hand. 
From  a  long  experience  in  swimming  the  writer  believes  that 
the  dangers  of  death  from  cramp  are  somewhat  exagger- 
ated. Long  swims  are  dangerous  unless  a  person  is  in  first- 
rate  physical  condition.  The  author  had  an  impressive  ex- 
perience in  the  water  with  a  swimmer  fresh  from  sedentary 
occupation  in  the  depressing  heat  of  a  city  who  undertook 
a  considerable  swim  and  gave  out  when  half  the  distance. 
Only  encouragement,  making  light  of  the  occurrence,  and 


62  THE    PREVENTION    OF   DISEASE 

slight  assistance  saved  the  swimmer  from  death  by  heart 
failure.  Those  who  faint  readily,  who  have  palpitation  or 
other  disturbance  of  the  heart,  the  elderly  not  habituated 
to  cold  water,  and  persons  who  do  not  react  satisfactorily 
to  cold  bath  should  refrain  from  outdoor  bathing. 
There  is  some  danger  in  diving  that  water  may  be  driven 
up  the  nose  and  into  the  ears  through  the  eustachian  tubes. 
Ear  abscess  may  result. 

A  word  as  to  swimming  tanks:  Eye,  ear,  throat,  and 
sexual  infections  are  sometimes  contracted  from  water  in 
common  use  by  bathers,  even  when  care  is  taken  to 
require  a  preliminary  shower,  etc.  Intestinal  germs  are 
not  infrequently  found  in  the  water.  Disinfection  with 
chlorid  of  lime,  copperas,  or  other  agent,  together  with 
frequent  change  of  water,  are  imperative. 

The  lukewarm  bath  (80°  to  90°  F.)  with  the  aid  of  soap 
has  merely  a  cleansing  effect  in  removing  dead,  scaly  par- 
ticles and  fatty  secretions  of  the  skin,  dirt,  and  sweat. 
The  functions  of  the  skin  in  eliminating  waste  matters 
in  the  sweat  are  thus  favored  and  the  work  of  the  kidneys 
relieved  to  this  extent.  The  common  pimples  (or  acne) 
of  youth  are  prevented  to  a  considerable  degree  by  daily 
cleanliness.  The  lukewarm  bath  is  suitable  for  the 
elderly  or  those  who  do  not  react  or  are  endangered  by 
cold  baths.  It  may  be  taken  at  any  time,  but  preferably 
not  directly  after  meals. 

The  Warm  Bath  (90°  to  100°  F.).— This  may  also  be 
used  for  cleansing  purposes,  and  is  not  likely  to  cause  dis- 
turbance after  meals,  the  temperature  being  so  near  that 
of  the  body.  Warm  baths  conduce  to  sleep  if  taken  before 
bedtime  and  followed  by  a  glass  of  hot  milk.  The  activity 
of  the  skin  is  favored,  and  persons  with  chronic  kidney 
troubles  and  hardening  of  the  arteries  should  have  warm 
baths  daily.  After  severe  exertion  warm  baths  tend  to 


BATHS  63 

remove  muscular  soreness  and  stiffness  of  the  joints. 
One  should  not  go  outdoors  in  cold  weather  soon  after  a 
warm  bath. 

The  Hot  Bath  (105°  to  110°  F.).— The  layman  is  often 
advised  not  to  take  hot  baths  except  by  professional  ad- 
vice. This  is  rather  absurd,  as  everybody  takes  them 
whether  or  no.  But  there  is  considerable  danger,  never- 
theless, in  hot  baths  for  persons  with  weak  hearts.  The 
heat  is  depressing  to  the  heart  and  dilates  the  blood-vessels 
of  the  skin,  taking  the  blood  away  from  the  brain.  This 
is  just  what  occurs  in  fainting — lack  of  blood  in  the  brain — 
and  fainting  may  occur  in  the  bath.  Hot  baths  should  not 
be  taken  after  meals  (blood  is  drawn  away  from  the  di- 
gestive organs)  nor  before  going  out  into  the  cold.  Hot 
baths  are  useful  in  preventing  colds  after  exposure  to  cold 
and  chilling.  They  relieve  intense  pain,  as  in  renal  colic 
caused  by  the  passage  of  stone  from  the  kidney,  and  will 
stop  convulsions  in  children.  Hot  baths  are  also  used  to 
cause  sweating  in  many  cases  of  poisoning  from  insufficient 
action  of  the  kidneys;  but  where  patients  are  weak  in 
such  conditions  hot  blankets  are  usually  wrapped  about 
them  in  bed.  In  taking  a  hot  bath  before  bedtime  a  cold 
cloth  should  be  worn  on  the  head  to  prevent  insomnia. 

The  Turkish  Bath  and  Hot-air  Cabinet  Baths. — Boxes 
or  cabinets  are  often  used  in  public  bath  places  and  at 
home  in  which  a  person  sits  tightly  enclosed  (in  a  nude 
state),  with  the  head  out  in  the  air  of  the  room.  These 
cabinets  are  heated  by  dry  air  from  electric  lights  or  steam 
pipes,  or  moist  air  is  used  by  the  evaporation  of  boiling 
water  over  a  lamp,  as  in  folding  cabinets  for  home  use. 
The  object  is  to  produce  excessive  sweating  for  the  pre- 
vention of  cold,  treatment  of  Bright's  disease  of  the  kid- 
neys, rheumatism,  etc.  A  cold  cloth  should  be  worn  on 
the  head.  A  person  may  remain  in  the  cabinet  for  twenty 


64  THE   PREVENTION   OF   DISEASE 

or  thirty  minutes,  providing  the  heat  is  not  too  oppressive. 
An  attendant  should  always  be  at  hand.  In  a  Turkish 
bath  a  hot-air  bath  is  given  at  120°  to  170°  F.,  the  subject 
breathing  the  air.  This  is  followed  by  a  hot  shower  and 
massage  in  a  room  filled  with  hot,  moist  air  (100° to  1 10°  F.), 
and  then  by  a  warm  shower  changing  to  cold,  with  thor- 
ough rubbing  and  drying.  Turkish  and  Russian  baths  are 
depressing  to  the  circulation,  as  are  all  hot  baths,  and 
should  not  be  taken  by  very  stout  persons  or  those  with 
weak  hearts.  Exposure  to  cold  is  dangerous  after  such 
baths,  and  for  that  reason  hot  baths  are  best  taken  at  home. 
If  taken  elsewhere  in  cold  weather  one  should  return 
home  in  a  closed  conveyance.  Some  forms  of  rheumatism 
and  stiffness  of  the  muscles  and  joints  after  severe  exercise 
are  much  benefited  by  hot  baths,  but  the  dry,  hot  air  of  a 
cabinet  is  less  depressing  and  exhausting  than  the  moist 
air,  especially  where  one  has  to  breathe  it,  as  in  the  Turkish 

bath  room. 

VENTILATION 

A  word  about  ventilation  may  not  be  amiss.  The 
older  ideas  concerning  ventilation  have  been  gradually 
slipping  away,  especially  the  belief  that  the  exhalation  of 
carbonic  acid  gas  from  the  lungs,  and  corresponding  con- 
sumption of  oxygen  by  occupants  of  a  room,  is  the  chief 
cause  of  bad  air  in  crowded  apartments.  Leonard  Hill's 
startling  experiment  with  a  group  of  persons  in  an  air- 
tight chamber,  in  which  the  oxygen  was  used  up  until 
matches  would  not  burn,  should  be  sufficient  to  shatter 
the  carbonic  acid  poisoning  theory.  The  occupants 
laughed  and  chatted  while  vainly  endeavoring  to  light 
cigarettes,  but  remained  perfectly  comfortable  so  long  as 
the  air  was  kept  cool. 

Modern  conceptions  of  ventilation  are  based  on  two 
fundamental  experiments:  "First,  that  subjects  immured 


VENTILATION  65 

in  close  chambers  and  exposed  to  the  heat,  as  well  as  the 
chemical  products  found  therein,  are  not  at  all  relieved  by 
breathing  pure  outside  air  through  a  tube.  Second,  that 
they  are  completely  relieved  by  keeping  the  air  artificially 
cooled  without  changing  the  air  at  all,  and  are  relieved  to  a 
considerable  extent  by  the  mere  cooling  effect  of  the 
electric  fan."  The  stale  air  of  crowded  and  ill-ventilated 
rooms  is  chiefly  air  which  has  become  overheated  and 
oversaturated  with  moisture  through  radiation  from 
its  human  occupants.  Good  ventilation  means  primarily 
and  essentially  constant  movement  of  cool  air. 

The  matter  of  the  best  degree  of  moisture  in  air  is  at 
present  unsettled.  Very  dry  air,  as  from  hot-air  furnaces 
containing  an  insufficient  amount  of  water  from  evaporat- 
ing pans,  is  notoriously  harmful  to  the  mucous  membranes 
and  predisposes  to  catarrh.  A  temperature  over  65°  or 
70°  F.  lessens  the  comfort  and  efficiency  in  work  and 
causes  slight  increase  in  body  heat  and  rise  in  pulse-rate. 
There  is  still  another  element  in  connection  with  ventila- 
tion, and  this  is  the  exhalations  from  the  mouths,  bodies, 
and  clothes  of  individuals  in  crowded  rooms,  which  aid  in 
making  the  air  stale  and  unpleasant.  Of  just  what  these 
emanations  consist  is  unknown,  but,  while  they  are  often 
not  perceived  by  occupants  of  a  room,  they  become  very 
objectionable  to  the  outsider  entering  a  crowded  apartment. 
Bad  air  of  ill-ventilated  rooms  resolves  itself  chiefly  into 
overheated  and  overmoist  air  having  insufficient  move- 
ment. It  is  corrected  by  reducing  the  temperature  below 
70°  F.  and  by  affording  some  means  of  generating  a  current 
of  air.  Emanations  from  many  individuals  also  play  a 
less  important  part  in  the  production  of  a  stale  or  foul 
atmosphere. 


66  THE   PREVENTION    OF   DISEASE 


There  is  a  vast  deal  of  nonsense  in  the  idea  fostered 
by  advertising  that  great  discrimination  is  necessary  in  the 
selection  of  a  toilet  soap.  As  a  matter  of  fact,  it  is  not  best 
to  use  soap  at  all,  habitually,  on  the  face  unless  the  skin  is 
oily  or  soiled.  One  toilet  soap  is  about  as  good  as  another 
if  it  is  a  pure  soap.  Soaps  are  made  by  boiling  fats  of 
different  kinds  with  alkalies.  The  cheaper  soaps,  as  yellow 
laundry  soaps,  contain  an  excess  of  alkali  which  is  useful  in 
removing  dirt  from  clothes,  but  irritates,  roughens,  and 
dries  the  skin  by  removing  its  natural  oily  secretion. 
Plain  castile  soap  or  any  of  the  more  expensive  soaps 
have  little  or  no  free  alkali  and  are  equally  serviceable. 
Medicated  soaps  have  not  much  value  because  the  soap 
is  in  contact  with  the  skin  such  a  short  time.  Some  per- 
sons find  special  soaps  agree  with  their  particular  skins 
more  than  others,  as  the  French  Societe"  Hygie"nique  soap 
(plain),  for  instance.  Cold  water  should  be  used  on  the 
face,  as  it  gives  color,  improves  tone,  and  tends  to  prevent 
wrinkles.  Warm  water  relaxes  the  skin  and  favors  chap- 
ping on  exposure  to  cold.  The  various  proprietary  toilet 
preparations  for  application  to  the  face  are  usually  harm- 
less, and  may  afford  much  satisfaction  to  the  users  and 
peculiar  profit  to  the  maker,  but,  as  a  rule,  are  wholly  un- 
necessary. The  application  each  night  of  cold  cream  to 
the  face  by  thorough  rubbing  will  preserve  the  complexion 
clear  and  free  from  wrinkles  better  than  any  other  appli- 
cation, and  the  same  is  useful  to  prevent  chapping  of  the 
skin  of  the  face  or  hands  in  winter.  In  summer  the  use 
of  rice  powder  on  the  face  will  tend  to  absorb  perspiration 
and  prevent  sunburn.  The  proprietary  face  powders  are 
much  more  expensive  and  no  more  effective,  while  the 
same  remarks  apply  to  the  face  creams  as  compared  to  cold 
cream. 


THE    COMPLEXION  67 

Freckles  due  to  a  deposit  of  pigment  in  the  skin  may 
be  caused  by  exposure  to  the  sun,  when  they  go  away 
spontaneously.  Then  there  are  permanent  freckles,  more 
often  in  blondes,  owing  to  some  inborn  peculiarity  of  the 
skin.  To  prevent  freckles  the  skin  must  be  protected 
from  the  sun  by  some  covering  as  a  hat,  veil,  or  gloves,  or 
covered  with  brown  grease  paint.  For  the  removal  of 
freckles  white  precipitate'  ointment  may  be  applied  each 
night.  To  prevent  and  cure  sunburn  nothing  is  better 
than  an  application  of  calamine  lotion,  and  is  more  agree- 
able than  the  brown  grease  paint,  also  efficient  as  a  pre- 
ventive. Both  the  precipitate  ointment  and  calamine 
lotion  are  kept  by  all  druggists. 

Acne. — In  acne  there  are  pin-head  and  larger  sharp- 
pointed  pink  or  reddish  pimples  with  a  central  opening 
often  containing  a  black  speck.  These  are  accumulations 
of  the  naturally  greasy  secretion  in  the  pores  of  the  skin, 
causing  irritation  of  the  surrounding  mtegument.  Some- 
times the  pimples  contain  matter  and  become  as  large  as  a 
pea.  Acne  pimples  occur  on  the  face,  shoulders,  chest, 
and  back.  The  disease  first  appears  somewhere  between 
the  twelfth  and  fifteenth  years,  and  usually  disappears  be- 
tween the  twenty-third  and  thirtieth  years.  General  care 
of  the  health  does  much  to  prevent  and  cure  the  disease. 
The  bowels  should  move  daily  (see  Constipation,  page 
260).  A  cold  bath  should  be  taken  daily,  followed  by 
vigorous  rubbing,  or  a  warm  bath  for  those  not  able  to 
take  a  cold  one. 

Regular  exercise  outdoors  is  also  imperative  in  play  or 
sports,  as  bicycling,  riding  horseback,  rowing,  etc.  Diet 
is  of  great  importance.  Candy,  pastry,  cakes,  and  pies 
should  be  forbidden,  also  tea  and  coffee.  If  the  patient  is 
thin  or  debilitated  and  pale,  he  must  be  built  up  with  good 
nourishing  food,  as  cream,  milk,  and  butter.  Cereals  are 


68  THE   PREVENTION   OF   DISEASE 

valuable,  with  the  exception  of  oatmeal,  which  sometimes 
seems  to  favor  acne.  Green  soap  and  water  should  be 
applied  to  the  face  every  night,  and  after  the  face  is  dried 
the  writer  has  found  that  the  application  of  a  proprietary 
preparation,  Dermatone,  is  very  effective  in  curing  the  dis- 
ease. 

Alkaline  mineral  water  is  also  useful  and  a  quart  bottle 
of  Vichy  Celestins  may  be  taken  daily.  In  place  of  this, 
six  or  eight  glasses  of  water,  with  a  pinch  of  salaratus  in 
each,  may  be  drunk  to  advantage  each  day. 

THE  HAIR 

Baldness  and  Dandruff. — Dandruff  is  the  commonest 
cause  of  baldness.  Dandruff  is  a  germ  disease  in  itself 
(Seborrhea  sicca)  which  is  contagious.  After  a  period 
of  two  to  seven  years  of  dandruff  and  dryness  of  the  hair, 
occurring  between  the  twentieth  and  thirtieth  years, 
baldness  begins.  As  the  baldness  increases,  usually  at 
the  top  of  the  head,  the  dandruff  diminishes.  Not  every- 
one with  dandruff  becomes  bald,  but  baldness  is  the  prob- 
able result,  especially  in  men.  In  dandruff  the  germ 
ultimately  destroys  the  roots  of  the  hairs,  which  then  fall 
out.  Prevention  is  most  important.  One  should  not 
wear  other  people's  headgear  or  use  their  brush  and  comb 
so  as  to  convey  the  germ  from  diseased  scalps  to  one's 
own.  Lassar  reproduced  dandruff  in  guinea-pigs  by  rub- 
bing the  scales  from  a  diseased  human  scalp  into  the 
backs  of  these  animals. 

To  cure  baldness  it  is  first  essential  to  prevent  or  cure 
dandruff,  and  the  baldness  will  then  be  cured  or  will  fail  to 
progress.  A  hair  wash  should  be  used  with  which  to  thor- 
oughly shampoo  the  scalp  night  and  morning  until  the  dan- 
druff disappears.  If  the  dandruff  returns,  the  wash  should  be 
again  applied.  It  is  possible  that  dust  may  transmit  the  germ 


THE    HAIR  69 

of  dandruff.  The  wash  is  composed  of  mercury  bichlorid, 
10  grains;  glycerin,  1  dram;  alcohol  (70  per  cent.),  8  ounces. 
This  is  poisonous  if  swallowed.  If  the  skin  of  the  scalp  be- 
comes too  dry,  a  little  sulphur  ointment  may  be  rubbed  in 
night  and  morning  in  place  of  the  wash.  The  scalp  may 
occasionally  be  washed  with  tincture  of  green  soap.  Most 
hair  tonics  and  pomades  are  of  no  value,  being  founded  on 
the  older  idea  that  the  scalp  needs  stimulating  in  baldness. 
Of  course,  there  are  other  causes  of  baldness  than  dan- 
druff, but  it  has  been  authoritatively  stated  (Jackson)  that 
70  per  cent,  of  all  cases  of  baldness  result  from  dandruff, 
although  there  is  undoubtedly  an  inherited  lack  of  resist- 
ance to  this  infection. 

Constant  wetting  of  the  hair  is  undesirable.  Frequent 
cutting  stimulates  the  growth  of  hair,  but  does  not  increase 
the  number  of  hairs.  Barbers  are  prone  to  advise  singeing 
to  make  the  hair  grow  thicker,  but  it  has  no  action  of  this 
kind. 

There  is  undoubtedly  danger  of  contracting  serious  in- 
fections from  the  barber  shop.  Syphilis  may  be  com- 
municated from  a  razor  not  thoroughly  sterilized.  Several 
germ  and  parasitic  skin  diseases  may  be  conveyed  from 
patients  by  barbers  to  other  customers  through  the  medium 
of  the  razor,  scissors,  brush  and  comb,  and  moist  towels. 
These  include  the  germ  disease  dandruff  from  brush  and 
comb,  also  barber's  itch,  an  eruption  on  the  bearded  chin 
and  upper  lip  of  inflamed  pimples  containing  matter  or 
pus.  This  disease  is  contagious  by  means  of  pus  germs 
(staphylococci) .  Ringworm  of  the  face  is  due  not  to  a 
worm,  but  to  a  vegetable  parasitic  fungus.  It  occurs  as 
circular,  partly  bald  patches  on  the  chin,  or  as  scaly  or 
weeping  reddish  lumps  arranged  in  a  circle,  on  which  the 
hair  is  more  or  less  wanting.  This  disease  may  be  con- 
tracted from  the  barber.  Besides  dandruff,  barber's  itch, 


70  THE   PREVENTION   OF   DISEASE 

and  ringworm,  it  is  possible  that  boils  and  carbuncles  may 
be  transmitted  by  the  barber's  appliances  from  one  person 
to  another.  The  only  way  to  surely  avoid  these  troubles 
at  a  barber  shop  is  to  furnish  all  one's  own  materials — 
razor,  soap,  brushes,  and  comb — and  to  have  only  a  clean 
dry  towel  used  on  the  face. 

It  is  not  safe  to  rely  upon  barbers'  methods  of  sterilizing 
their  utensils. 

FINGER-  AND  TOE-NAILS 

While  the  finger-nails  should  be  cut  so  that  they  will 
follow  in  outline  the  contour  of  the  fingers,  it  is  best  to  trim 
the  toe-nails  in  a  straight  line  across  the  ends  of  the  toes 
to  better  prevent  the  effects  of  pressure  on  them  by  the 
boots. 


CHAPTER  IV 

GERM  DISEASES 

,  Vaccination,  Small-pox,  Typhoid  Fever,  Asiatic  Cholera,  Dysen- 
tery, Diphtheria,  Hydrophobia,  Lockjaw,  Scarlet  Fever,  Measles, 
Mumps,  Whooping-cough,  Bubonic  Plague. 

v 

VACCINATION  AND   SMALL-POX 

THE  most  successful  examples  of  vaccination  against 
germ  diseases  at  the  present  time  include  vaccination  for 
small-pox,  typhoid  fever,  diphtheria,  lockjaw,  hydrophobia, 
dysentery,  cholera,  plague,  cerebrospinal  meningitis.  It 
might  at  first  sight  appear  disheartening  to  find  many  per- 
sons and  sects  still  actively  opposing  vaccination  for  small- 
pox after  considerably  more  than  a  century's  absolute 
proof  of  its  efficacy.  But  this  very  fact  is  a  natural  result 
of  the  success  of  vaccination  in  almost  eradicating  one  of 
the  most  fearful  scourges  of  mankind  (Magna  Pesta), 
responsible  formerly  for  nearly  half  a  million  deaths  in 
Europe  alone.  In  1760  it  was  estimated  that  small-pox 
carried  off  from  one-thirteenth  to  one-fourteenth  of  each 
generation,  and  but  one  person  in  twenty  escaped  the  dis- 
ease before  the  days  of  vaccination.  So  that  at  the  present 
time  the  foolish  may  safely  combat  vaccination  without 
being  punished  for  their  folly  by  taking  small-pox.  But 
the  deluded  are  not  by  any  means  always  born  idiots,  for 
Herbert  Spencer  late  in  life  wrote  an  essay  attempting  to 
prove  vaccination  a  fallacy. 

Lady  Wortley  Montagu,  in  1718,  introduced  from  Asia 
into  Europe  the  practice  of  inserting  matter  from  the 

71 


72  THE   PREVENTION   OF   DISEASE 

small-pox  eruption  into  scratches  made  in  the  skin  of  sus- 
ceptible persons,  and  by  so  doing  reduced  the  death-rat€ 
to  1  per  cent.,  but  at  the  same  time  greatly  increased  the 
prevalence  of  the  disease  in  a  mild  form.  It  had  long  been 
known  in  England  and  elsewhere  that  accidental  inocula- 
tion with  cowpox  while  milking  would  render  the  inocu- 
lated person  safe  from  small-pox. 

Acting  on  this  knowledge,  in  1774  Benjamin  Jesty,  a 
Dorsetshire  farmer,  who  had  himself  escaped  small-pox 
by  acquiring  the  cow  disease,  proceeded  to  rub  some  of  the 
matter  from  the  cow  eruption  into  scratches  in  the  skin 
of  his  wife  and  his  two  infants,  who  remained  proof  against 
small-pox.  This  is  the  first  recorded  instance  of  vaccina- 
tion. Again,  in  1791,  Peter  Plett,  in  Holstein,  having  seen 
doctors  inoculate  small-pox  into  people,  and  knowing  the 
accepted  tradition  that  milkers  who  had  acquired  cowpox 
were  safe  from  small-pox,  tried  the  experiment  himself  of 
inoculating  cowpox.  Being  tutor  in  a  family,  he  had  the 
temerity  to  transfer  the  matter  from  the  eruption  of  cow- 
pox  into  incisions,  made  with  a  pocket  knife,  on  the  back  of 
the  hands  of  his  three  pupils.  But  so  successful  was  this 
rough-and-ready  experiment  that  three  years  later  these 
vaccinated  children  were  the  only  ones  spared  in  an  out- 
break of  small-pox. 

Jenner  is  given  the  credit  of  being  the  originator  of  vac- 
cination, but  while  this  is  not  so,  he  is  justly  regarded 
as  the  author  or  father  of  vaccination  because  it  was  he 
who  first  introduced  it  to  mankind,  and  his  was  the  con- 
ception that  by  this  method  small-pox  might  be  abolished 
from  the  world,  and  to  it  he  devoted  his  life  and  strength. 
His  first  successful  vaccination  was  in  1796. 

Cowpox  is  generally  regarded  as  a  form  of  small-pox 
modified  by  passing  through  the  cow.  The  disease  attacks 
chiefly  young  cows,  is  mild,  and  the  eruption,  similar  to 


VACCINATION    AND    SMALL-POX  73 

that  seen  on  the  vaccinated  arm  of  a  man,  is  commonly 
confined  to  the  udder.  The  vaccine  matter  is  obtained  by 
inoculating  the  bellies  of  calves  with  vaccine  matter  taken 
from  other  calves  or  from  vaccinated  human  beings,  which 
has  been  examined  microscopically  to  prove  its  absence 
from  harmful  germs.  The  matter  having  been  rubbed  into 
scratches  on  the  clean  skin  of  the  calf,  the  eruption  is 
scraped  off  between  the  fourth  and  sixth  day,  and  this 
material  is  then  ground  in  a  machine  and  mixed  with  gly- 
cerin to  kill  all  germs,  except  those  of  cowpox. 

The  calf  is  killed  and  examined  carefully  to  prove  its 
healthy  condition.  A  successful  vaccination  will  invariably 
afford  protection  against  small-pox  after  eight  to  eleven 
days  from  the  time  of  vaccination.  As  small-pox  requires 
from  nine  to  twelve  days  to  develop,  one  may  avoid  small- 
pox if  vaccinated  within  the  first  three  or  four  days  after 
exposure,  and  even  if  vaccination  be  delayed  for  a  week  the 
small-pox  will  be  of  a  mild  character.  Practically  nobody 
is  immune  to  vaccination,  but  it  is  not  safe  to  infer  that 
because  a  vaccination  or  re  vaccination  does  not  "take," 
the  person  is  immune  to  small-pox. 

It  will  naturally  be  asked  How  long  does  vaccination 
protect  one  from  small-pox?  This  cannot  be  answered  by 
any  stated  period,  because  it  is  variable,  from  months  to 
many  years.  The  safest  method  to  pursue  is  that  in  which 
children  are  vaccinated  between  the  ages  of  six  months  and 
two  years;  again,  when  they  enter  school;  and  a  third  time 
within  a  period  of  ten  years,  and  after  this  whenever  there 
is  special  danger.  A  simple  test  has  recently  been  used  to 
show  if  a  person  is  immune  to  small-pox  at  any  period  fol- 
lowing successful  vaccination.  A  drop  of  vaccine  is  rubbed 
into  a  single  small  scratch  in  the  skin.  If  the  person  is 
immune,  a  red  area  will  surround  the  scratch  within  twenty- 
four  hours,  which  may  increase  within  forty-eight  hours, 


74  THE    PREVENTION   OF   DISEASE 

and  then  rapidly  fade  away.  This  is  called  the  "immunity 
reaction."  Compulsory  vaccination  and  re  vaccination 
should  be  required  in  all  states,  and  has  been  upheld  by  the 
Supreme  Court  of  the  United  States. 

The  dangers  of  vaccination  are  frequently  exaggerated, 
and  "compulsory  school  attendance  is  far  more  dangerous 
than  compulsory  vaccination."  The  death-rate  in  Ger- 
many has  been  3.5  in  every  million  vaccinated.  Almost  all 
the  severe  cases  of  complication  after  vaccination  are  avoid- 
able, being  due  to  local  infection  from  carelessness  of  the 
doctor  or  patient  in  caring  for  the  wound.  Vaccination 
is  a  surgical  procedure  and  should  always  be  carried  out  as 
such.  The^arm  should  be  vaccinated- and  not  the  leg,  un- 
less the  patient  remains  in  bed  during  the  course  of  the 
vaccination,  since  inflammation  of  a  serious  character  will 
often  follow.  The  arm  should  be  washed  with  soap  and 
water,  and  then  with  alcohol,  and  the  skin  allowed  to  dry 
before  the  vaccination  is  done. 

Three  scratches  an  inch  long  and  three-quarters  of  an 
inch  apart,  but  not  deep  enough  to  draw  blood  in  large 
drops,  are  to  be  made  with  a  sharp  sterilized  knife.  Cross 
scratches  near  together  are  forbidden  in  Germany,  because 
a  scab  will  then  form,  which  causes  irritation,  scratch- 
ing, and  infection.  A  light  dressing  of  six  layers  of  sterile 
gauze  should  be  kept  over  the  vaccination  by  strips  of 
adhesive  plaster  to  protect  it  from  unclean  clothing. 

It  may  be  superfluous  to  give  facts  which  may  be  used 
to  refute  the  unbelievers  in  vaccination,  but  as  more  than 
40  per  cent,  of  adults  are  un vaccinated  in  some  states  and 
a  large  proportion  of  the  remaining  60  per  cent,  are  not 
properly  vaccinated,  it  should  not  be  amiss.  The  classical 
example  in  this  country  is  that  of  Benjamin  Waterhouse, 
Professor  of  Physics  at  Harvard,  who  on  July  8,  1800,  first 
introduced  vaccination  into  the  United  States  by  vac- 


VACCINATION    AND  .SMALL-POX  75 

cinating  seven  of  his  own  children.  In  Boston,  in  1802, 
19  boys  were  vaccinated,  and  almost  two  months  later 
12  of  these  boys  were  inoculated  with  small-pox;  nothing 
followed.  At  the  same  time  2  un vaccinated  boys  were 
inoculated  with  small-pox  and  both  took  the  disease. 
Finally,  the  whole  19  vaccinated  children  were  again  in- 
oculated from  matter  taken  from  the  fresh  eruptions  from 
the  two  boys  with  small-pox,  but  small-pox  did  not  follow 
in  any  single  case. 

"This  is  one  of  the  most  crucial  experiments  in  the  his- 
tory of  vaccination,  and  fully  justified  the  conclusion  of  the 
(Boston)  Board  of  Health — 'cowpox  is  a  complete  security 
against  small-pox'  "  (Osier).  There  is  not  the  slightest 
danger  for  one  recently  and  successfully  vaccinated  in 
caring  for  small-pox  patients,  and  newspaper  heroism  is 
thus  easily  acquired.  A  modern  instance  of  the  success 
of  vaccination  is  seen  in  the  Philippines  since  our  occupa- 
tion. After  1907  systematic  vaccination  in  the  six  prov- 
inces near  Manila  (with  a  population  of  over  a  million, 
and  having  from  time  immemorial  a  death-rate  of  over 
6000  from  small-pox)  has  resulted  in  no  death  in  the  suc- 
cessfully vaccinated  and  but  a  few  scattered  cases  of  small- 
pox. Small-pox  attacking  a  person  who  has  been  vac- 
cinated within  five  or  six  years  is  usually  of  a  mild  type  and 
is  called  "varioloid."  Pitting  rarely  occurs  in  these  cases, 
but  occasionally  small-pox  appearing  within  a  few  years 
after  vaccination  is  severe  and  even  fatal. 

Vaccination  is,  then,  the  chief  preventive  means  against 
small-pox.  In  addition,  isolation  of  the  sick  in  a  guarded 
house  or  in  a  hospital,  and  vaccination  of  exposed  per- 
sons, who  should  be  watched  daily  for  two  weeks,  are 
essential.  The  patient's  discharges  should  be  covered 
with  1  part  of  chlorid  of  lime  in  8  parts  of  water,  and  the 
attendants  not  be  permitted  to  leave  the  premises.  After 


76  THE   PREVENTION  OP  DISEASE 

the  disease  has  terminated  the  mattresses  should  be  burned 
and  the  bedding  and  clothing  boiled  for  half  an  hour.  It  is 
being  generally  accepted  by  medical  authorities  that  the 
contagious  eruptive  skin  diseases,  as  scarlet  fever,  measles, 
and  small-pox,  are  chiefly  communicated  by  the  secretions 
of  the  eyes,  nose,  skin  and  throat,  and  by  direct  contact  of 
persons  with  these  secretions — not  through  the  air  by 
means  of  scales  or  some  imaginary  emanation  from  the 
skin.  If  every  one  were  properly  vaccinated  small-pox 
would  disappear,  and  an  adult  acquiring  the  disease  now-a- 
days  should  rather  be  regarded  as  an  object  of  shame,  and 
might  not  unfairly  be  subject  to  fine  or  punishment. 

TYPHOID  FEVER 

Vaccination  against  typhoid  fever  is  now  the  most  im- 
portant means  of  prevention,  but  one  which  has  not  yet 
been  popularly  appreciated  and  accepted.  The  principle 
of  vaccination  is  that  by  the  injection  under  the  skin  of 
dead  germs  of  typhoid  fever  there  is  a  production  in  the 
patient  of  antibodies,  thus  affording  an  active  immunity 
to  the  disease  such  as  occurs  after  an  attack  of  typhoid 
fever. 

It  is  rare  that  persons  have  typhoid  fever  more  than 
once,  but  occasionally  second  and  third  attacks  occur.  In 
1897  Sir  A.  E.  Wright  vaccinated  17  persons  against 
typhoid  fever,  and  was  the  first  at  this  time  to  recommend 
the  treatment  as  a  general  preventive  measure  against 
typhoid  fever.  In  the  preparation  of  this  vaccine  the 
typhoid  fever  germs  are  grown  on  suitable  media,  and  then 
mixed  with  salt  solution  and  killed  by  exposure  to  heat 
(129.2°  F.)  for  one  hour,  when  they  are  further  diluted  with 
salt  solution  to  a  standard  strength,  a  small  amount  of 
antiseptic  is  added,  and  a  dose  of  some  500,000,000  or 
1,000,000,000  dead  germs  is  put  up  in  hermetically  sealed 


TYPHOID    FEVER  77 

glass  tubes.  The  vaccine  is  tested  to  show  its  freedom 
from  living  germs,  and  by  injection  into  animals  to  prove 
its  immunizing  strength  and  freedom  from  harmful 
germs,  especially  those  of  lockjaw.  Three  doses  are  in- 
jected under  the  skin  at  about  the  site  of  ordinary  vac- 
cination of  the  arm,  at  intervals  of  seven  to  ten  days, 
using  a  dose  of  500,000,000  the  first  time  and  1,000,000,000 
of  the  dead  germs  at  each  of  the  later  injections.  There 
is  some  swelling  and  redness  at  the  site  of  the  injections, 
and  there  may  be  fever,  headache,  nausea,  and  a  feeling 
of  weariness  for  a  short  time  after  the  injections,  but  no 
dangerous  or  fatal  result  has  occurred  in  the  hundreds 
of  thousands  of  persons  so  treated.  In  about  two-thirds 
of  the  cases  there  are  no  general  symptoms  produced. 
The  injection  is  made  in  the  late  afternoon,  and  neither 
alcohol  nor  violent  exercise  should  be  taken  thereafter. 

Typhoid  fever  has  often  been  more  fatal  than  bullets  in 
war.  Thus  in  the  Boer  War  over  7000  died  through 
wounds  and  over  8000  by  typhoid.  Of  our  troops  in  the 
Spanish- American  War,  243  died  of  wounds  and  1580 
perished  of  typhoid  fever. 

Before  typhoid  vaccination  began  there  were  10,759 
soldiers  at  camp  at  Jacksonville  in  1898,  and  over  2000 
cases  of  typhoid  with  248  deaths. 

After  vaccination  there  were  12,801  troops  at  San  An- 
tonio, under  approximately  the  same  conditions  and  length 
of  time,  with  only  2  cases  and  no  deaths.  Since  1911  vac- 
cination has  been  compulsory  throughout  the  United 
States  Army  in  persons  under  forty-five  years  of  age. 
Among  80,000  to  90,000  persons  thus  vaccinated  there 
were  but  3  cases  of  typhoid  fever  in  1913  and  no  deaths, 
as  against  several  hundred  cases  in  previous  years,  with 
from  22  to  74  deaths.  Owing  to  vaccination,  for  the  first 
time  in  1913  in  any  army  no  deaths  from  typhoid  fever 


78  THE    PREVENTION    OF   DISEASE 

occurred  in  the  United  States  troops.  Typhoid  vaccine 
is  now  supplied  free  in  many  states,  and  its  use  in  civil  life 
should  become  general  and  customary. 

All  children  and  young  adults  should  be  vaccinated, 
as  typhoid  fever  is  a  disease  of  the  young,  and  vaccination 
is  less  disturbing  to  children,  rarely  keeping  them  from 
school  or  play.  The  dose  is  regulated  by  their  weight. 
Vaccination  is  especially  indicated  for  all  colleges,  insti- 
tutions, and  boarding  schools,  and  particularly  in  hospitals 
and  dispensaries  for  doctors,  nurses,  and  attendants. 
Travelers  in  the  country  and  in  unsanitary  cities,  in- 
habitants of  typhoid-ridden  regions,  and  for  all  campers 
the  use  of  vaccination  as  a  preventive  for  typhoid  should 
be  the  rule. 

At  present  it  is  not  known  how  long  the  protection 
against  typhoid  fever,  conferred  by  the  vaccination,  will 
last.  In  the  army  re  vaccination  against  typhoid  fever 
and  small-pox  is  required  on  enlistment  every  four  years, 
but  it  is  hoped  that  but  three  vaccinations  during  life,  as 
advised  in  the  case  of  small-pox,  will  be  necessary  to  pro- 
tect an  individual  for  life  against  typhoid.  Typhoid  vac- 
cination is  as  important  as  vaccination  against  small-pox, 
and  there  is  sufficient  evidence  to  recommend  it  for  all 
healthy  children  and  young  adults  in  any  part  of  the 
United  States. 

How  We  Take  Typhoid  Fever  and  Means  of  Avoiding  It. 
—While  the  prevalence  of  typhoid  fever  in  the  United 
States  is  perhaps  half  what  it  was  forty  years  ago,  yet 
it  is  two  to  five  times  higher  than  it  is  in  enlightened 
European  countries  today.  As  every  case  of  typhoid 
depends,  in  the  last  analysis,  upon  the  direct  or  indirect 
transmission  of  typhoid  germs  from  the  excrement  or 
urine  of  patients  (or  carriers  of  germs)  by  "food,  fingers, 
or  flies,"  to  a  susceptible  person,  the  disposal  of  excretions 


TYPHOID    FEVER  79 

becomes  of  chief  importance.  In  cities  this  is  the  main 
object  of  a  public  sewage  system,  since  not  only  the  germs 
of  typhoid  fever  but  those  of  dysentery,  diarrhea,  cholera, 
and  (rarely)  tuberculosis,  together  with  the  eggs  of  round- 
worm,  tapeworm,  and  hookworm  are  transmitted  to  man 
by  means  of  the  excrement.  Indeed,  if  typhoid  germs  were 
kept  out  of  every  human  body  for  eighteen  months  it  is 
probable  that  the  human  disease  would  forever  disappear. 

In  the  country  districts  the  care  of  human  excretions  is 
in  the  hands  of  individuals.  Here  human  excreta  may 
contaminate  wells  by  leaking  out  of  privies  into  surface 
soil  and  thus  into  loosely  capped  wells.  It  may  be  dis- 
seminated by  the  feet  of  humans  and  animals  when  on  the 
surface  of  the  ground,  and  it  may  pollute  milk  and  other 
food  through  soiled  fingers  and  flies,  or  by  direct  contact, 
when  human  excrement  is  used  for  manure  in  growing 
vegetables  eaten  raw,  as  strawberries,  lettuce,  radishes,  etc. 

The  proper  construction  of  privies  becomes  then  of 
prime  importance.  They  should  be  fly-proof  and  the 
receptacle  for  the  excreta  should  be  water-tight.  The 
privy  must  have  a  tight  roof,  sides,  door,  and  floor  to 
exclude  flies.  Air-holes  for  ventilation,  in  the  sides  near 
the  top,  should  be  screened  for  the  same  reason.  On  the 
tight  floor  is  erected  the  seat.  The  front  of  the  seat  is 
hinged  so  as  to  open.  Through  this  opening  is  placed  a 
large  galvanized  iron  pail  under  the  hole  in  the  seat.  The 
front  of  the  seat  is  then  closed  and  fastened  until  it  is 
necessary  to  empty  the  receptacle.  The  hole  in  the  seat 
must  be  always  tightly  covered  when  not  in  use,  to  keep 
flies  from  contact  with  the  excretions.  This  is  accom- 
plished by  causing  the  cover  to  automatically  fall  when  not 
resting  against  the  back  of  the  occupant.  A  projection 
from  the  back  wall  of  the  privy  will  hold  the  cover  forward 
so  as  to  rest  upon  the  back  of  the  occupant  of  the  seat. 


80  THE   PREVENTION    OF   DISEASE 

When  the  person  rises  the  cover,  therefore,  falls  by  gravity, 
and  a  careless  individual  cannot  leave  the  seat  uncovered. 
The  contents  of  the  receptacle  may  be  kept  fairly  odorless 
by  scattering  dry  earth  on  it  each  time  the  closet  is  used. 
When  the  pail  is  full  of  excrement  it  should  be  buried  more 
than  18  inches  deep  and  covered  with  lime.  Human 
excrement  should  not  be  used  for  manure. 

The  germs  of  typhoid  fever  enter  the  body  through  the 
mouth  in  food  and  water  contaminated  with  excrement  or 
urine  of  typhoid  patients. 

Typhoid  fever  is  not  communicated  from  the  sick  to 
persons  merely  entering  the  room  of  the  patient,  but  at- 
tendants who  handle  the  patient's  body,  his  clothing,  and 
vessels  containing  his  discharges  often  acquire  the  disease 
by  soiling  their  hands  and  thus  their  food.  By  sterilizing 
everything  after  contact  with  the  patient,  even  boiling 
his  bath  water,  by  covering  the  discharges  with  1  part  of 
freshly  slaked  lime  in  8  parts  of  water  for  an  hour,  and  by 
the  attendants  wearing  rubber  gloves  and  long-sleeved 
aprons,  communication  through  contact  with  the  patient 
may  be  averted. 

Water  and  milk  are  the  chief  sources  of  typhoid  fever. 
The  Chinese  never  drink  raw  milk  or  unboiled  water  and 
rarely  have  typhoid  fever,  while  the  disease  is  common 
among  the  white  people  living  in  China — a  commentary 
on  our  civilization.  Milk  is  the  most  common  cause  of 
typhoid  fever  in  cities  having  a  good  water-supply  (see 
page  284).  Typhoid  germs  are  conveyed  to  milk  by 
patients  or  "carriers,"  persons  who  have  recovered  from 
the  fever,  but  excrete  germs  in  their  urine  and  excrement 
for  months  or  years  afterward.  Four  per  cent,  of  typhoid 
convalescents  become  "carriers." 

Typhoid  germs  enter  water  from  sewage,  privies,  and 
surface-water  contaminated  with  the  discharges  of  typhoid 


TYPHOID    FEVER  81 

patients.  Typhoid  fever  germs  usually  perish  in  filthy 
water  within  two  days  or  a  week,  but  may  live  in  still  water 
in  reservoirs  and  wells  for  several  months,  and  in  ice  as  long 
as  three  months.  Most  large  cities  in  civilized  countries 
have  an  unpolluted  water-supply,  otherwise  one  must  only 
drink  boiled  water. 

Raw  vegetables  soiled  by  contaminated  water  or  human 
excrement  or  by  handling,  and  raw  oysters  taken  from  beds 
polluted  by  sewage  are  occasional  sources  of  typhoid 
fever.  Flies  are  common  carriers  in  camps  and  elsewhere, 
flying  directly  from  typhoid  discharges  to  alight  on  food. 
They  were  the  great  sources  of  the  disease  in  the  southern 
camps  of  our  troops  in  the  Spanish-American  War.  In 
camps  where  large  amounts  of  contaminated  dust  may 
settle  on  the  food  we  have  another  possible  source  of  ty- 
phoid infection.  Then  there  are  the  human  "carriers," 
noted  above,  who  live  among  us  for  years  unsuspected  and 
innocent  of  their  malign  influence  until  some  energetic 
health  officer  traces  an  outbreak  of  typhoid  fever  to  the 
unfortunate  cook,  waiter,  or  dairy  employee  or  other 
"carrier"  engaged  in  handling  food. 

It  has  recently  been  stated  by  Lumsden  (United  States 
Public  Health  Service,  May,  1915)  that  the  use  of  typhoid 
vaccine  lessens  the  susceptibility  to  typhoid  fever  by  75  per 
cent,  or  more,  yet  persons  so  protected  may  succumb  to  an 
enormous  number  of  typhoid  germs  such  as  may  be  found 
in  milk  contaminated  by  the  infection.  Therefore 
typhoid  vaccination  cannot  wholly  supplant  sanitary  pre- 
ventive measures.  The  susceptibility  to  typhoid  fever 
differs  in  the  same  individual  at  different  times  and  does 
not  depend  upon  general  robustness.  When  numbers  of 
persons  drink  the  same  water  containing  typhoid  germs 
perhaps  only  1  in  10  or  1  in  100  will  take  typhoid  fever, 
so  that  susceptibility  is  an  important  factor. 
6 


82  THE    PREVENTION    OF   DISEASE 

ASIATIC  CHOLERA 

Cholera  is  a  disease  in  which  the  infecting  germ  always 
enters  the  mouth  in  food  or  drink,  inhabits  the  intestines, 
and  passes  away  in  the  bowel  discharges.  It  is  similar  in 
these  respects  to  dysentery  and  typhoid  fever,  and,  in 
fact,  cholera  is  no  more  contagious  than  typhoid  fever, 
according  to  Osier.  India  has  been  the  home  of  the  disease 
from  time  immemorial,  and  not  until  the  nineteenth  cen- 
tury did  it  invade  Europe.  While  cholera  is  frequently 
brought  to  seaports  in  the  United  States  and  Great  Britain, 
it  is  easily  kept  from  spreading  by  modern  methods  of 
sanitary  control.  Within  recent  times  cholera  has  been 
prevalent  in  the  near  and  far  East,  India,  Russia,  Italy, 
North  Africa,  Asia  Minor,  Arabia,  and  Turkey.  While 
cholera  was  one  of  the  most  common  diseases  in  the  Philip- 
pines after  the  American  occupation,  it  has  been  almost 
extinguished  by  our  Public  Health  Service. 

The  disease  is  transmitted  by  the  germs  escaping  in  the 
bowel  discharges  of  the  sick,  convalescent,  and  the  ap- 
parently healthy,  who  may  act  as  "carriers."  Eight  per 
cent,  of  376  healthy  persons  were  found  to  be  carriers  in 
Manila.  Here,  again,  cholera  infection  is  transmitted 
precisely  as  in  typhoid  fever,  water  being  the  commonest 
medium  of  infection ;  then  raw  food  of  all  kinds  which  has 
become  contaminated  with  infected  water,  flies  from  bowel 
discharges,  or  fingers  soiled  by  handling  patients,  or  from 
the  personal  discharges  in  carriers.  Unboiled  milk,  cheese, 
and  butter  are  frequent  sources  of  infection ;  also  raw  fruits, 
salads,  and  vegetables,  as  lettuce,  water  cress.  Cholera 
germs  may  live  on  butter,  bread,  or  fresh  meat  for  a  week, 
so  that  the  eating  of  recently  cooked  food  and  drink  (in- 
cluding water  and  milk)  must  be  insisted  upon  during 
cholera  epidemics.  The  boiling  of  all  utensils  used  to 
prepare,  hold,  or  serve  food  is  also  essential.  Some  thick- 


ASIATIC    CHOLERA  83 

skinned  fruits  and  vegetables  may  be  eaten  with  safety 
after  immersing  them  in  boiling  water  a  few  moments,  as 
oranges,  apples,  tomatoes,  and  mangoes.  The  hands 
must  be  frequently  washed  and  always  before  eating, 
and  the  same  care  should  be  observed  by  cooks  and  waiters. 
All  food  should  be  carefully  screened  from  flies. 

Infection  through  air  does  not  occur  because  cholera 
germs  are  readily  killed  by  drying.  Mineral  waters  ob- 
tained from  cholera-free  regions  and  boiled  water,  or  milk, 
tea,  coffee,  and  chocolate  are,  of  course,  allowable.  The  use 
of  alcohol  favors  cholera  infection  and  any  food  which  irri- 
tates the  digestive  tract  and  leads  to  diarrhea.  Indiges- 
tible food,  an  excessive  amount  of  fruit,  fruit  juices,  or 
cream  are  thus  harmful  in  cholera-infected  regions.  Con- 
stipation may  be  relieved  by  rectal  injections.  Chilling 
of  the  body,  worry,  overexertion,  and  fright  make  persons 
more  susceptible  to  cholera. 

A  flannel  bandage  should  be  worn  continually  about  the 
abdomen  to  prevent  diarrhea.  There  is  not  much  danger 
to  persons  during  a  cholera  epidemic  if  they  can  follow  out 
these  precautions.  Even  doctors  and  nurses  who  are  con- 
stantly exposed  to  cholera  do  not  frequently  take  it,  while 
those  handling  soiled  clothes  in  laundries  are  especially 
prone  to  infection. 

Vaccines,  consisting  of  both  living  and  dead  cholera 
germs,  are  injected  under  the  skin  to  prevent  the  disease 
and  diminish  the  mortality  in  those  of  the  inoculated 
who  do  acquire  it.  The  vaccines  appear  to  greatly  lessen 
the  chances  of  infection  in  cholera  epidemics,  and  also  to 
very  considerably  lower  the  mortality  in  the  inoculated, 
but  produce  considerable  local  and  general  disturbance. 
They  have,  however,  been  used  quite  extensively  and  suc- 
cessfully in  the  Philippines,  India,  and  Russia.  After 
taking  cholera  germs  into  the  digestive  tract  from  two  to 


84  THE   PREVENTION   OF   DISEASE 

five  days  are  required  to  develop  the  disease.  In  many 
cases  no  symptoms  are  produced,  and  these  vary  from  the 
mildest  diarrhea  to  the  constant  draining  away  of  rice- 
water  discharges  and  collapse.  Isolation  of  those  sick 
with  cholera  and  the  most  careful  disinfection  of  their 
discharges  and  clothing  and  cleanliness  of  the  hands  are 
practised  precisely  as  recommended  in  the  care  of  typhoid 
patients  (see  page  80)  to  prevent  contagion  from  cholera 
patients.  Microscopic  examination  of  the  bowel  dis- 
charges of  suspicious  persons  with  diarrhea  will  determine 
the  existence  of  the  cholera  germs. 

DYSENTERY 

Dysentery  is  acquired  like  typhoid  fever  through  water 
or  food  containing  the  dysentery  germs  escaping  from  the 
bowels  of  patients.  Again,  like  typhoid  fever,  it  may  be 
acquired  by  persons  who  handle  the  patient's  body,  cloth- 
ing, and  vessels  holding  his  discharges.  More  often  the 
disease  is  taken  by  drinking  contaminated  well-water  in 
the  country  or  other  polluted  drinking-water,  or  by  bathing 
in  polluted  streams. 

Dysentery  is  the  great  destroyer  of  life  in  the  tropics  and 
is  common  in  summer  in  temperate  regions,  particularly 
in  military  camps  and  institutions,  and  as  the  "summer 
diarrhea"  of  children.  The  laity  often  call  any  severe  diar- 
rhea dysentery,  but  true  dysentery  begins  with  diarrhea 
or  loose  movements  of  the  bowels,  together  with  fever, 
loss  of  appetite,  weakness  and  pains  in  the  bowels,  and 
then  the  true  dysenteric  symptoms  are  seen.  These  con- 
sist in  painful  straining  and  the  passage  of  slime  and  blood. 

Milk  is  a  common  means  of  transmitting  the  disease 
through  polluted  water  used  in  washing  milk  utensils. 
Flies  also  carry  the  germs  directly  from  the  bowel  move- 
ments of  patients  to  food.  Then,  again,  persons  who  have 


DYSENTERY  85 

dysentery  in  a  very  severe  form  and  recover  may  harbor 
the  germs  in  their  bodies  for  a  long  time  and  even  carry 
them  over  from  one  warm  season  to  another.  In  other 
words,  we  have  dysentery  carriers  as  well  as  typhoid  car- 
riers. Raw  vegetables  may  also  be  sources  of  infection 
when  saturated  with  polluted  water.  The  means  of  pre- 
vention are  precisely  those  outlined  for  typhoid  fever;  that 
is,  the  drinking  of  boiled  water  and  milk,  and  the  avoid- 
ance of  raw  vegetables  and  fruits  growing  on  the  ground, 
as  strawberries,  the  observance  of  the  same  care  in  the 
handling  of  dysentery  patients  and  their  bowel  discharges, 
and,  finally,  the  use  of  a  vaccine  in  epidemics  in  the  case 
of  those  much  exposed.  The  vaccine  is  made  from  cultures 
of  the  dysentery  germs  in  the  same  manner  as  typhoid 
vaccine  and  administered  in  the  same  doses  subcutane- 
ously.  It  will,  however,  only  protect  the  individual  for 
from  eight  to  ten  weeks  against  infection  with  dysentery. 
A  serum  prepared  like  that  used  in  diphtheria  is  of  great 
value  in  the  treatment  of  this  disease. 

We  have  been  speaking  of  the  more  common  form  of 
dysentery,  or  bacillary  dysentery,  as  it  is  technically  called. 
There  is  another  form,  the  amebic  dysentery,  common  also 
in  tropical  countries,  in  India,  Egypt,  the  Philippines  and 
Southern  United  States,  and  rarely  throughout  this 
country.  This  form  of  dysentery  is  more  apt  to  be  chronic 
and  is  not  so  prone  to  occur  with  the  suddenness  and  fever 
of  the  more  common  tropical  or  bacillary  dysentery;  but 
the  disease  is  produced  by  the  lowest  form  of  animal  life—- 
the ameba — which  can  readily  be  seen  in  the  bowel  dis- 
charges under  the  microscope,  and  this  test  is  the  only  real 
means  of  separating  the  two  forms  of  dysentery.  Liver 
abscess  is  one  of  the  common  complications  of  the  amebic 
form  of  dysentery.  The  treatment  by  subcutaneous  injec- 
tions of  the  active  ingredient  of  ipecac  (emetin)  and  in- 


86  THE    PREVENTION   OF   DISEASE 

jections  into  the  bowels  of  pure  kerosene  is  quite  different 
from  that  for  bacillary  dysentery.  As  water  appears  to  be 
the  chief  carrier  of  the  ameba,  the  precautions  to  be  adopted 
in  the  prevention  of  amebic  dysentery  are  the  same  as 
those  for  typhoid  fever  and  bacillary  dysentery.  It  is 
important  to  avoid  agents  which  may  irritate  the  bowel, 
and  so  offer  a  favorable  field  for  the  growth  of  dysentery 
germs  in  warm  weather;  these  include  the  small  fruits  and 
unripe  fruits,  coarse  cereals,  and  rye  or  whole  wheat 
bread,  and  powerful  cathartics. 

DIPHTHERIA 

It  has  been  found  that  persons  are  much  more  resistant 
to  diphtheria  at  some  ages  than  at  others.  Thus,  by  means 
of  the  Schick  test,  it  appears  that  at  birth  80  per  cent,  of 
infants  are  immune,  and  as  high  as  90  per  cent,  of  adults, 
while  of  children  from  one  to  five  years  but  40  to  50  per 
cent,  are  immune.  Since  the  discovery  of  antitoxin  it  has 
been  used  in  an  enormous  number  of  cases  to  prevent 
diphtheria.  The  protection  afforded  by  antitoxin  lasts 
but  about  three  weeks,  however,  and  so  its  use  must  be 
repeated  every  three  weeks,  or  it  may  be  only  given  to 
exposed  persons  or  to  those  who  are  about  to  be  exposed. 

It  will  be  seen  that  young  children  are  particularly  sus- 
ceptible and,  therefore,  those  who  most  require  such  pro- 
tection. 

Briefly,  antitoxin  is  the  liquid  portion  of  the  blood  (or 
the  blood-serum)  of  horses  which  have  been  made  immune 
against  diphtheria. 

Diphtheria  germs  are  grown  on  the  surface  of  broth,  the 
germs  are  killed  by  adding  an  antiseptic,  and  then  the 
filtered  broth  containing  the  poison  (toxin)  produced  by  the 
growth  of  the  germs  is  injected  into  healthy  young  horses 
every  few  days  in  gradually  increasing  doses.  After 


DIPHTHERIA  87 

several  weeks  of  this  treatment  the  animal  is  bled,  the  red 
cells  are  allowed  to  settle,  and  the  clear,  straw-colored  se- 
rum is  drawn  off  after  the  blood  has  stood  awhile.  This 
is  antitoxin  and  must  be  tested  as  to  its  strength,  which  is 
stated  in  units.  A  unit  is  the  smallest  amount  of  this  serum 
which  will  protect  a  guinea-pig  from  death  after  receiving 
a  minimum  fatal  dose  of  diphtheria  poison.  To  protect 
children  from  diphtheria  a  dose  of  antitoxin  containing 
1000  units  should  be  injected  under  the  skin,  but  in  adults 
is  is  safer  to  inject  some  3000  units  for  this  purpose.  In 
the  actual  treatment  of  diphtheria  the  dose  is  2000  units 
in  ordinary  cases  in  children  and  10,000  units  in  severe 
cases.  For  the  treatment  of  diphtheria  in  adults  the  aver- 
age dose  is  10,000  units,  and  in  severe  cases  30,000  units, 
which  is  increased  to  50,000  or  150,000  units  in  advanced 
and  desperate  cases.  In  either  children  or  adults  antitoxin 
is  injected  under  the  skin  for  protection  or  in  the  treatment 
of  mild  cases ;  in  more  severe  cases  it  is  injected  deep  into 
a  muscle,  and  in  serious  cases  it  is  injected  immediately 
into  a  vein.  It  is  rarely  necessary  to  repeat  doses  of  anti- 
toxin when  they  are  given  in  proper  dosage  at  the  onset. 

There  is  considerable  prejudice  against  antitoxin  as  a 
preventive  in  diphtheria,  which,  however,  has  but  slight 
basis. 

In  the  first  place,  it  is  practically  a  sure  preventive  of 
diphtheria  after  exposure  if  given  at  any  time  before  the 
disease  is  manifest,  and  in  larger  doses  an  almost  sure  cure 
if  given  within  the  first  few  hours  after  the  development  of 
diphtheria.  Thus,  in  New  York,  of.  80,000  persons  given 
antitoxin  to  prevent  diphtheria,  but  2  in  1000  developed 
the  disease  and  but  1  died.  The  disadvantages  of  anti- 
toxin are  as  follows:  In  from  seven  to  ten  days  after  its 
injection  (rarely  from  one  to  twenty-one  days)  various 
forms  of  itching  rashes  appear  in  some  cases,  and  they  may 


88  THE    PREVENTION   OF   DISEASE 

be  accompanied  by  weariness,  fever,  vomiting,  pain  in  the 
joints,  and  some  swelling  of  the  glands.  These  symptoms 
are  usually  not  severe  and  disappear  in  three  or  four  days. 
But  rarely  death  has  been  caused  by  antitoxin  under  cer- 
tain conditions,  as  when  persons  have  previously  received 
antitoxin  after  an  interval  of  a  week  or  any  length  of  time 
greater  than  a  week.  Also  in  the  case  of  persons  subject 
to  asthma,  or  those  who  are  affected  by  the  smell  of 
horses,  and  in  some  children  with  enlarged  glands.  The 
fatalities  are  so  unusual  that  in  40,000  cases  given  antitoxin 
at  the  Boston  City  Hospital  none  occurred. 

But  harm  from  the  use  of  antitoxin  may  always  be  pre- 
vented by  injecting  but  2  drops  and  waiting  three  hours 
for  any  unpleasant  symptoms,  as  this  dose  cannot  be 
dangerous.  After  this  time  the  regular  dose  may  be  given, 
or,  if  the  small  dose  caused  unpleasantness,  the  antitoxin 
may  be  injected  in  gradually  increasing  amounts.  Such 
a  course  should  always  be  pursued  in  persons  who  have 
formerly  taken  antitoxin,  in  those  subject  to  asthma  and 
sensitive  to  horses,  and  in  any  who  may  fear  the  treatment. 
The  concentrated  serum  now  used  is  much  less  likely  to 
produce  any  rashes,  as  it  is  the  amount  of  the  horses' 
blood  that  causes  trouble  and  it  has  nothing  to  do  with 
the  antitoxin. 

In  children's  hospitals  it  is  the  custom  to  give  all  the 
patients  antitoxin  at  regular  intervals,  to  prevent  the  oc- 
currence of  diphtheria,  and  in  the  Boston  Children's 
Hospital  this  has  been  done  for  years  without  any  untoward 
result.  While  antitoxin  is  not  usually  regarded  as  a  vac- 
cine, yet  any  material  inoculated  into  persons  to  prevent 
disease  is  a  vaccine. 

In  cases  of  diphtheria  the  patient  should  remain  in  a 
room  from  which  all  the  movables,  as  rugs  and  carpets, 
etc.,  have  first  been  taken. 


DIPHTHERIA  89 

Dogs  and  cats  should  be  excluded.  Cats  occasionally 
have  the  disease  and  dogs  can  carry  diphtheria.  The 
attendant  should  gargle  her  throat  frequently  with  a 
saturated  solution  of  boric  acid  or  with  listerine,  but  there 
is  no  preventive  so  sure  as  antitoxin.  The  nurse  should 
have  her  hair  covered  with  a  cap  and  her  dress  by  a  long- 
sleeved  gown,  which  should  be  left  in  the  room  when  she 
leaves  it.  Everything  taken  from  the  room  should  be 
first  boiled  or  soaked  for  an  hour  in  5  per  cent,  solution  of 
carbolic  acid.  A  person  is  more  likely  to  catch  the  disease 
if  the  patient  coughs  or  sneezes  in  his  face.  The  disease  is 
chiefly  communicated  by  convalescents  who  go  about  be- 
fore the  germs  have  left  their  throats,  or  by  exposed  but 
healthy  persons  who  may  carry  the  germs  in  their  throats 
without  taking  the  disease.  Quarantine  is  not  removed 
nor  the  patient  permitted  to  go  abroad  until  officially 
released  by  the  Board  of  Health  when  the  throat  is  free 
from  diphtheria  germs. 

Finally,  the  question  arises,  Shall  every  person  who  has 
by  any  possibility  been  exposed  to  diphtheria,  or  is  likely  to 
be  exposed,  be  given  a  preventive  dose  of  antitoxin?  Most 
of  the  leading  health  authorities  advise  such  a  course,  and 
this  has  been  my  rule  unless  special  reasons  to  the  contrary 
exist.  In  cases  of  unsanitary  and  crowded  buildings,  and 
in  institutions  for  children,  hospitals,  asylums,  and  schools, 
when  an  epidemic  of  diphtheria  threatens,  all  the  inmates 
should  be  immunized.  In  private  practice  among  the 
well-to-do  it  has  been  the  custom  of  some  leading  physicians 
not  to  give  antitoxin  to  adults  who  may  have  been  exposed 
to  diphtheria,  and  to  keep  exposed  children  under  close 
observation  and  withhold  antitoxin  unless  sore  throat  ap- 
pears in  them.  Diphtheria  requires  from  two  to  seven 
days  to  develop  after  exposure,  more  often  only  two  days. 
But  it  seems  to  the  writer  that  the  safer  course  is  to  give 


90  THE    PREVENTION   OF   DISEASE 

antitoxin  to  all  persons  who  may  have  been  exposed  to 
diphtheria;  the  only  objection  is  the  inconvenience,  there 
being  no  danger  if  the  precautions  already  described  are 
followed.  .  • 

The  new  Schick  test  may  allow  us  to  forego  the  injection 
of  antitoxin  in  adults  slightly  exposed,  and  is  useful  in 
institutions  where  large  numbers  of  persons  may  need 
protection  against  an  outbreak  of  diphtheria. 

The  Schick  test  informs  us  as  to  the  susceptibility 
of  a  person  to  diphtheria.  By  its  use,  as  stated  above, 
some  90  per  cent,  of  adults,  50  per  cent,  of  children,  and 
perhaps  80  per  cent,  of  infants  appear  to  be  immune. 
Infants  inherit  antitoxin  from  their  mothers,  it  passing 
into  their  circulation  before  birth.  The  antitoxin  disap- 
pears to  a  considerable  degree  after  the  age  of  two  or 
later,  and  so  children  then  become  largely  susceptible  to 
diphtheria.  In  later  life  there  is  again  often  immunity 
established  by  a  previous  mild  and  unrecognized  attack 
of  diphtheria.  Carriers  of  diphtheria  germs  always  give 
a  negative  Schick  test  and  are  always  immune  because 
of  the  large  amount  of  antitoxin  in  their  bodies.  In 
active  diphtheria  the  Schick  test  is  aways  positive,  owing 
to  a  lack  of  antitoxin  in  the  patient.  The  Schick  test  is 
valuable  in  persons  who  may  be  dangerously  susceptible 
to  antitoxin.  But  if  it  is  negative  in  such  persons,  there 
will  be  no  need  for  them  to  be  given  antitoxin  since  they 
are  not  susceptible  to  diphtheria.  In  the  Schick  test  1| 
drops  of  dilute  diphtheria  toxin  are  injected  into  the  skin 
of  a  person.  Directly  a  white  spot  appears  at  the  site 
of  the  needle  puncture,  and  if  the  individual  is  susceptible 
to  diphtheria,  some  redness,  swelling,  and  a  pimple  will 
appear  at  this  point  within  twenty-four  to  forty-eight 
hours. 

In  persons  not  susceptible  to  diphtheria  the  antitoxin 


DIPHTHERIA  91 

in  their  bodies,  neutralizes  the  irritant  effect  on  the  skin 
of  the  toxin  injected,  and  so  no  local  inflammation  occurs 
at  the  site  of  the  injection.  The  toxin  used  in  the  test  is 
a  poison  developed  in  the  growth,  of  diphtheria  germs.  It 
is  standardized  for  the  test,  so  that  the  human  dose  is 
equal  to  one-fiftieth  of  a  fatal  guinea-pig  dose. 

In  children  exposed  to  diphtheria  it  is  safer  to  wipe  off 
secretions  from,  the  throat  for  examination  for  the  presence 
of  the  diphtheria  germ.  In  adults  not  greatly  exposed 
the  Schick  test  may  be  used.  By  it  about  two-thirds  of 
exposed  adults  will  be  found  not  to  need  antitoxin  (Park). 
If  a  person  has  not  recently  been  exposed  to  diphtheria, 
but  is  liable  to  future  exposure,  he  may  be  given  vaccine 
treatment  which  affords  protection  against  diphtheria  for 
one  or  two  years,  while  antitoxin  gives  immunity  for  only 
ten  days  or  so.  The  vaccine  is  a  strong  solution  of  diph- 
theria toxin  neutralized  by  antitoxin,  and  is  injected  into 
the  skin  of  the  back.  This  method  requires  ten  days  to 
render  a  person  immune,  while  antitoxin  confers  immediate 
immunity.  No  bad  results  followed  the  vaccination  of 
700  children  against  diphtheria.  Owing  to  the  short 
period  of  development  of  diphtheria — two  to  seven  days 
after  exposure — it  is  safer  not  to  wait  for  the  results  of  the 
Schick  test,  but  to  give  a  protective  or  immunizing  dose  of 
antitoxin  as  soon  after  exposure  as  possible,  except  in  adults 
slightly  exposed.  But  in  those  individuals  subject  to 
asthma,  and  in  those  who  have  had  antitoxin  on  a  previous 
occasion,  and,  therefore,  may  be  poisoned  by  a  second  dose, 
the  vaccine  may  be  used  as  a  safe  and  effective  substitute 
for  antitoxin  as  a  protective  agency  against  diphtheria. 


92  THE  PREVENTION   OF  DISEASE 

HYDROPHOBIA 

While  hydrophobia  is  a  comparatively  rare  disease  in 
man,  it  would  be  much  more  common  were  it  not  for  the 
Pasteur*  vaccination.  The  disease  is  greatly  more  fre- 
quent in  dogs,  and  outbreaks  have  occurred  in  most  states 
in  the  Union — and  for  the  first  time,  recently,  on  the  Pacific 
coast.  In  1911,  4625  persons  were  treated  for  hydropho- 
bia, that  is,  given  the  preventive  treatment;  and  there 
were  98  deaths  from  the  disease  in  the  whole  United  States. 
It  is  curious  that  although  hydrophobia  has  been  known  to 
exist  since  300  B.  c.,  there  are  many  deluded  persons  who 
still  deride  its  entity,  and  not  so  long  ago  an  English  writer 
stated  that  hydrophobia  was  a  disease  which  attacks  man 
and  impels  him  to  kill  dogs. 

Anyone  who  has  observed  hydrophobia  in  man  or  beast 
could  as  easily  doubt  its  existence  as  one  seeing  a  case  of 
small-pox.  The  germs  of  the  disease  have  not  yet  been 
isolated. 

One  should  know  in  a  general  way  the  symptoms  of 
madness  or  rabies  in  dogs  to  avoid  the  disease.  The 
animal  is  altered  in  disposition  and  habits.  He  is  sul- 
len or  very  friendly,  nervous,  and  restless,  sees  imag- 
inary objects,  and  often  shuns  the  light  and  hides.  He 
frequently  licks  and  swallows  all  kinds  of  objects  and 
is  subject  to  vomiting.  Later  he  has  difficulty  in  swal- 
lowing, and  quite  commonly  he  is  thought  to  have  a 
bone  in  his  throat.  Attempts  to  swallow  water  are  con- 
stant and,  in  the  later  stages  of  the  disease,  this  is  im- 
possible. In  the  second  stage  the  animal  leaves  home  and 
travels  great  distances,  biting  men,  animals,  and  inanimate 
objects,  often  returning  to  die.  The  voice  is  changed  into 
a  hoarse  howl,  the  tail  droops,  the  head  is  depressed,  with 
staring,  glazed,  bloodshot  eyes,  and  the  animal  is  insensible 
to  pain,  persons,  or  surroundings;  the  gait  is  unsteady  and 


HYDROPHOBIA  93 

the  patient  becomes  emaciated  and  repulsive.  Periods  of 
excitement  and  biting  occur  in  the  presence  of  noises, 
animals,  and  men,  alternating  with  exhaustion  and  quiet- 
ude if  the  dog  is  not  disturbed.  The  third  stage  is  shown 
by  exhaustion  and  paralysis  of  the  hind  parts  and  the  lower 
jaw.  The  latter  happens  early  in  what  is  known  as  dumb 
rabies  and  the  lower  jaw  drops,  the  tongue  is  dry  and 
covered  with  stringy  saliva,  and  there  is  inability  to  either 
bite,  howl,  or  swallow.  If  the  dog  truly  has  rabies,  death 
is  almost  invariably  certain  in  from  four  to  ten  days,  except 
in  dumb  rabies,  when  death  may  be  more  delayed.  This 
form,  known  as  "drop  jaw,"  leads  owners  to  think  dogs 
have  a  bone  in  the  throat.  While  they  cannot  bite,  it  is 
exceedingly  dangerous  to  handle  their  mouths,  for  the 
saliva  may  infect  the  slightest  abrasion  of  the  hands,  as 
about  hang-nails. 

When  persons  are  bitten  by  a  dog  supposedly  rabid  a 
diagnosis  is  imperative.  The  surest  way  is  to  keep  the 
animal  caged  for  inspection  where  this  is  possible.  His 
death  and  the  examination  of  the  brain  will  settle  the  diag- 
nosis absolutely  if  the  result  is  positive.  If  the  suspected 
dog  is  alive  and  in  good  health  after  ten  days  rabies  is 
highly  improbable. 

If  the  suspected  animal  runs  away,  dies,  or  is  killed  in- 
side of  ten  days  the  Pasteur  treatment  is  advisable  unless 
laboratory  examination  of  the  brain  of  the  animal  can  be 
made  and  is  negative.  Even  this  is  not  to  be  wholly  relied 
upon  in  early  stages  of  the  disease,  and  if  the  animal  has 
bitten  several  persons,  or  its  actions  have  been  suspicious, 
the  treatment  should  be  taken.  It  has  been  found  that  in 
3  per  cent,  of  truly  rabid  dogs  the  examination  of  the  brain 
will  not  show  evidences  of  the  disease,  so  persons  whose 
hands  have  been  licked  by  rabid  dogs  should  also  take  the 


94  THE   PREVENTION   OF   DISEASE 

Pasteur  treatment,  as  Park  records  8  cases  in  which  hydro- 
phobia has  been  acquired  in  this  manner. 

The  head  and  neck  of  a  suspected  animal  should  be  sent 
on  ice  to  a  laboratory  for  examination  if  the  dog  has  been 
killed  or  dies,  or  the  brain  and  upper  nart  of  the  spinal 
cord  may  be  sent  in  glycerin  and  will  keep  much  longer  than 
if  sent  on  ice. 

The  writer  was  able  to  locate  by  advertising  the  body 
of  a  dog  which  had  been  killed  and  buried  a  week  after 
biting  six  persons,  and  examination  of  the  animal's  brain 
and  inoculation  of  it  into  rabbits  proved  the  disease  to  be 
rabies.  Most  of  the  bitten  persons  had  already  begun  the 
Pasteur  treatment  and  none  developed  hydrophobia. 

The  period  required  for  development  of  the  disease, 
after  infliction  of  a  bite,  usually  varies  from  two  to  eight 
weeks  in  man  and  dogs  or,  on  the  average,  forty-nine 
days  in  man.  The  bites  of  rabid  animals  should  be  im- 
mediately burned  with  a  hot  iron  or  cauterized  by  fuming 
nitric  acid,  followed  by  a  strong  solution  of  saleratus  in 
water  and  then  by  alcohol. 

Or  the  tissue  surrounding  the  bite  should  be  cut  away. 
Either  of  these  methods  are  of  value,  even  if  they  must  be 
deferred  as  long  as  twenty-four  hours,  but  the  sooner 
treatment  is  begun  the  better.  On  the  average,  but  15 
per  cent,  of  persons  bitten  take  hydrophobia.  If  the  bare 
skin  is  bitten  the  chances  of  acquiring  hydrophobia  are 
much  increased. 

The  Pasteur  treatment  should  be  begun  as  soon  after 
receiving  the  bite  as  possible,  and  it  is  successful  in  pre- 
venting hydrophobia  in  99  per  cent,  of  persons  recently 
bitten.  The  vaccine  matter  is  prepared  from  the  spinal 
cords  of  rabbits  which  have  been  given  the  disease,  the 
germs  being  killed  in  part  by  drying  the  cords  for  varying 
periods  of  time.  The  cords  which  have  been  longest  dried 


LOCKJAW  95 

are  weakest  and  are  first  used,  rubbed  up  with  a  little 
water,  and  injected  under  the  skin. 

The  treatment  is  given  daily  for  three  weeks.  Half  a 
dozen  manufacturing  firms  and  the  Hygienic  Laboratory 
at  Washington  send  out  the  vaccine  by  mail.  Glycerin 
and  carbolic  acid  are  added  as  preservatives. 

No  harmful  effects  whatever  follow  the  use  of  vaccine  in 
the  vast  number  of  cases.  Rarely  local  paralysis  has  been 
caused  by  the  treatment,  which  may  later  disappear.  In 
4282  persons  vaccinated  for  rabid  dog  bites  by  the  New 
York  City  Health  Department  there  were  7  cases  of  paral- 
ysis and  2  deaths  attributable  to  the  treatment.  Hydro- 
phobia is  surely  fatal.  The  latest  figures  are  those  of 
Simon,  who  finds  paralysis  occurs  in  1  case  in  every  2177 
persons  treated.  Since  but  1  person  in  200  treated  devel- 
ops hydrophobia,  and  since  30  (untreated)  persons  in  200 
who  have  been  bitten  by  mad  dogs  contract  the  disease 
and  (always)  die,  the  disadvantages  of  treatment  are  neg- 
ligible. Animals  who  have  been  bitten  by  supposedly  mad 
dogs  should  be  immediately  destroyed.  The  muzzling  of 
dogs  for  six  months  within  a  radius  of  20  miles  from  the 
location  of  the  first  case  of  rabies  will  stamp  out  the  dis- 
ease. 

LOCKJAW 

/ 

Lockjaw,  or  tetanus,  is  a  rare  disease,  so  that  a  physician 

seldom  sees  more  that  a  case  or  two  in  a  lifetime  unless 
practising  in  a  region  in  which  the  disease  is  indigenous. 
In  this  country  lockjaw  more  frequently  occurs  in  Long 
Island,  Connecticut,  the  Hudson  River  Valley,  and  the  At- 
lantic States.  The  germs  naturally  live  in  the  intestines  of 
horses,  cattle,  and  dogs,  and  so  dust  and  dirt  contaminated 
with  droppings  from  these  animals  are  dangerous  when 
they  soil  a  wound.  Lockjaw  sometimes  arises  without  the 
presence  of  any  wound,  but  in  that  case  it  is  thought  that 


96  THE   PREVENTION   OF   DISEASE 

some  slight  unperceived  abrasion  may  have  led  to  the  in- 
fection. The  germs  and  their  spores  are  most  difficult  to 
kill,  and  live  for  years  and  years  on  inanimate  objects. 
They  exist  in  the  soil,  and  especially  in  stable  dirt.  Then 
there  are  certain  wounds  which  offer  a  favorable  field  for 
their  entrance  and  growth.  The  germs  of  lockjaw  do  not 
grow  well  when  exposed  to  air,  so  that  punctured  wounds, 
which  are  not  freely  opened  to  the  air,  are  most  dangerous, 
especially  if  made  by  a  nail  or  sharp  object  entering  the 
foot  which  has  been  contaminated  with  manure  or  stable 
dirt,  or  soil  .of  any  kind.  The  entrance  of  foreign  bodies 
into  the  wound,  as  clothing,  the  wad  of  blank  cartridges,  or 
simply  dirt,  adds  greatly  to  the  likelihood  of  lockjaw.  All 
wounds  in  which  there  is  much  bruising  or  tearing  of  the 
tissues  and  punctured  wounds  or  those  penetrating  deeply, 
especially  when  contracted  in  the  streets  or  about  stables, 
are  chiefly  subject  to  lockjaw,  and  tetanus  antitoxin  is  indi- 
cated. 

The  wounds  are  usually  on  the  hands  and  feet.  Before 
the  general  suppression  of  the  Glorious  Fourth-of-July 
an  extraordinary  number  of  cases  of  tetanus  occurred  from 
toy  pistol  wounds  on  these  occasions. 

There  are  three  essentials  in  the  treatment  of  such 
wounds.  The  first  is  thorough  opening  of  deep,  punc- 
tured wounds;  and,  second,  washing  them  out  thoroughly 
with  boiled  water  or  antiseptic  solution  and  keeping  them 
open  by  strips  of  sterilized  gauze.  When  this  is  done,  and 
a  surgeon  should  always  attend  the  case  if  possible,  and 
may  have  to  give  an  anesthetic,  there  is  less  danger  of 
lockjaw.  The  third  essential,  especially  in  regions  where 
lockjaw  is  known,  is  a  dose  of  antitoxin  given  within  a  few 
hours  after  the  injury,  and  it  will  almost  invariably  pre- 
vent the  occurrence  of  the  disease.  The  dose  may  lae  re- 
peated at  the  end  of  ten  days  if  there  is  a  nasty  wound 


SCARLET  FEVER,  SCARLATINA  97 

which  may  be  still  harboring  tetanus  germs  and  their 
poison.  This  is  said  to  be  over  100  times  more  powerful 
than  strychnin,  and  to  be,  indeed,  the  most  virulent  of 
known  poisons. 

Tetanus  antitoxin  is  made  by  injecting  horses  with 
gradually  increasing  doses  of  the  poison  developed  by  the 
germs  of  this  disease,  and  at  the  end  of  four  or  five  months 
some  of  their  blood  is  withdrawn  and,  after  the  red  portion 
settles,  the  upper,  pale,  straw-colored  serum  is  removed 
and  is  called  antitoxin,  because  it  possesses  antibodies 
elaborated  in  the  horse  which  will  neutralize  the  poison  of 
lockjaw  in  man.  It  is  injected  in  the  same  way  as  diph- 
theria antitoxin  and  is  without  danger,  except  as  noted  in 
that  connection  (see  page  87). 

Colonel  Roosevelt  was  given  a  dose  of  tetanus  antitoxin 
almost  immediately  after  the  attempt  on  his  life,  during 
one  of  his  public  addresses,  because  of  the  greatly  bruised 
character  of  his  wound,  produced  by  the  impact  of  the 
would-be  assassin's  bullet  on  his  spectacle  case,  and  thus 
on  his  chest. 

SCARLET  FEVER,  SCARLATINA 

Scarlatina  is  another  name  for  scarlet  fever  and  not  a 
milder  form  of  the  disease,  as  the  layman  often  appears  to 
believe.  Persons  are  not  so  susceptible  to  scarlet  fever  as 
to  measles  and  many  escape  infection. 

The  disease  is  more  fatal  than  measles,  although  not  so 
much  so  in  children  as  most  persons  think.  The  death- 
rate  in  1000  cases  at  the  Boston  City  Hospital  was  about 
10  per  cent.  Most  of  the  fatal  cases  occur  in  children  under 
six  years  of  age,  and  90  per  cent,  under  the  age  of  ten,  so 
that  every  protection  must  be  afforded  children.  Infants 
at  the  breast  are  rarely  attacked,  however.  The  safest 
method  is  to  send  children  who  have  not  had  the  disease 

7 


98  THE    PREVENTION    OF   DISEASE 

out  of  the  house  as  soon  as  a  case  of  scarlet  fever  develops. 
Thus,  Chapin  found  in  Providence  that,  while  over  one- 
quarter  of  the  children  in  houses  containing  a  case  of  scar- 
let fever  took  the  disease  when  they  remained  in  their  home, 
but  7  per  cent,  were  affected  when  they  were  sent  away. 
That  is,  some  50  of  1000  children  sent  from  infected  homes 
developed  the  disease  when  away,  and  19  more  came  down 
with  it  when  they  returned. 

The  disease  requires  for  its  development — from  time  of 
exposure  to  the  first  appearance  of  sickness — from  four 
to  twenty  days,  oftenest  ten  to  fourteen  days. 

Formerly  the  scales  of  skin  during  peeling  were  thought 
to  be  the  medium  for  conveying  the  germs  of  scarlet  fever. 
Now  the  secretions  from  nose,  throat,  and  ears  (when  these 
run,  as  often  happens  from  ear  abscess)  are  considered  the 
most  important  sources  of  contagion.  Injection  of  the 
mucus  from  the  nose  and  throat  of  scarlet  fever  patients 
under  the  skin  of  ten  children  reproduced  severe  cases  of 
the  disease  in  every  child.  But,  the  germ  having  not  yet 
been  identified,  it  is  uncertain  that  the  peeling  skin  is  not 
also  a  medium  for  its  transmission.  Many  persons  have 
such  mild  attacks  that  they  go  about  unsuspected  and 
spread  the  disorder,  while  others  communicate  it  during 
the  last  few  days  before  they  come  down  with  the  disease, 
and  still  others  convey  it  during  convalescence. 

Such  individuals  may  contaminate  milk,  and  large  out- 
breaks in  cities  have  been  traced  to  milk  infected  in  this 
way.  In  Boston,  in  1910,  some  842  cases  of  scarlet  fever 
suddenly  occurred  from  drinking  a  contaminated  milk  in 
which  the  germs  flourish.  The  only  sure  pjreventive  is  to 
drink  milk  properly  pasteurized  in  the  bottle,  or  boiled 
milk  (see  page  287).  One  epidemic  Was  traced  to  a  milk- 
man who  had  a  discharging  sore, on  his  finger  following  an 
attack  of  scarlet  fever,  and  the  discharge  had  evidently 


SCARLET    FEVER,    SCARLATINA  99 

contaminated  the  milk  supply.  Isolation  of  the  patient 
in  a  room  connected  with  an  anteroom  is  the  best  precau- 
tion against  spread  of  the  disease.  How  long  he  shall  stay 
there  is  at  present  uncertain — anywhere  from  three  to 
nine  weeks,  according  to  different  authorities.  Four  to 
six  weeks'  isolation  are  more  commonly  required  in  prac- 
tice, or  until  all  peeling  and  discharge  from  the  nose, 
throat,  ears,  or  other  parts  cease. 

All  unnecessary  articles  should  be  first  removed  from  the 
sick  room,  especially  such  as  cannot  be  readily  disinfected, 
as  books,  curtains,  rugs,  upholstery,  etc.  There  is  slight 
danger  of  communication  of  the  disease  by  the  attendant  if 
the  case  is  well  managed,  but  Chapin's  figures  show  that 
this  is  not  usually  practicable.  If  the  nurse  wears  a  wash- 
able cap  and  gown  covering  her  clothing,  and  thoroughly 
washes  her  hands  and  clothes,  and  leaves  the  gown  and  cap 
in  the  anteroom  on  leaving  the  patient,  there  is  little  danger 
of  contagion.  The  father  of  the  family  under  such  condi- 
tions may  go  to  business  as  usual.  Thorough  disinfection 
of  the  sick  rooms  with  formalin  and  scraping  off  the  wall 
paper  and  repapering,  with  burning  of  all  unnecessary 
infected  articles,  should  be  done  after  the  patient  is  well. 
Children  who  have  been  sent  away  should  not  return  until 
at  least  two  months  from  the  beginning  of  the  scarlet 
fever,  and  later  if  there  is  any  likelihood  of  infection  from 
catarrh  in  the  nose  or  throat  or  discharge  from  the  ear  of 
the  patient.  Where  disinfection  cannot  be  done  by  a 
proper  health  board  the  formalin  candles  sold  by  druggists 
may  be  used,  but  at  least  twice  the  quantity  recommended 
should  be  employed,  and  the  room  must  be  sealed  tight 
(by  pasting  strips  of  paper  over  all  cracks)  for  twelve  hours 
while  the  fumigation  is  going  on.  Everything  which  comes 
out  of  the  room  must  be  first  disinfected,  either  by  boiling 
or  soaking  in  1  : 1000  solution  of  corrosive  sublimate,  or,  in 


100  THE   PREVENTION   OF   DISEASE 

the  case  of  metals,  a  5  per  cent,  solution  of  carbolic  acid. 
Mattresses,  pillows,  and  carpets  are  hard  to  disinfect  except 
in  municipal  steam-sterilizing  plants.  Persons  rarely  have 
scarlet  fever  more  than  once,  and  many  adults,  as  doctors 
who  are  constantly  exposed,  escape  it  altogether. 

MEASLES 

Measles  is  a  disease  every  one  is  supposed  to  have,  but 
this  need  not  necessarily  be  if  attempts  at  prevention  were 
general.  It  is,  indeed,  true  that  no  person  and  no  age  are 
immune,  but  more  care  should  be  taken  to  avoid  exposure. 
This  remark  particularly  applies  to  children  who  are  made 
by  measles  much  more  susceptible  to  pneumonia,  tubercu- 
losis, rickets,  etc. ;  but  there  appears  to  be  a  feeling  among 
parents  that  it  is  just  as  well  to  allow  children  to  acquire 
measles,  because  they  will  have  it  any  way,  and  since  it  is 
more  severe  in  adults.  The  contrary  is  actually  the  case, 
it  having  been  shown  that,  in  the  same  region  and  in  the 
same  class  of  people,  the  mortality  from  measles  was  8.1 
in  children  and  but  1.3  among  adults  (Ftirbringer).  It  is 
true  that  infants  under  six  months  are  less  often  sufferers, 
but  this  is  probably  due  to  the  fact  that  they  are  kept 
more  secluded  and  not  so  apt  to  be  exposed. 

The  period  of  development,  from  exposure  to  the  begin- 
ning of  the  disease,  is  from  "seven  to  eighteen  days;  often- 
est  fourteen  days."  Therefore,  children  who  have  been 
exposed  should  keep  away  from  school  for  two  weeks,  and 
children  living  in  the  vicinity  of  measles  should  be  sent 
away  to  avoid  the  contagion.  Measles  is  peculiar,  in  that 
it  is  most  contagious  during  three  to  four  days  before  the 
eruption  occurs,  and  the  contagion  dies  out  within  three  or 
four  days  after  the  appearance  of  the  eruption.  Whether 
there  is  any  contagion  from  the  patient  during  peeling  is 
questionable.  Experiments  indicate  there  is  not. 


MUMPS  101 

If  parents  isolated  children  just  so  soon  as  fever  and  other 
signs  of  any  sickness  appeared,  on  general  principles,  the 
opportunity  for  taking  contagious  diseases  would  be  much 
curtailed. 

This  is  notably  important  in  measles,  which  comes  on 
like  a  feverish  cold,  with  running  at  the  nose,  sneezing, 
fever,  cough,  and  sore  eyes.  A  child  or  adult  in  this  condi- 
tion should  be  isolated  in  an  airy  room,  with  a  temperature 
of  65°  F.,  and  all  persons,  especially  children,  should  be 
kept  out,  except  the  attendant.  The  patient  should  stay 
in  bed  until  the  eruption  has  wholly  gone,  and  in  his  room 
until  all  peeling  is  over,  a  period  of  from  two  to  four  weeks. 
The  germs  of  measles  live  but  two  hours  after  they  leave 
the  body,  so  that  disinfection  of  the  sick  room  is  unneces- 
sary. Bathing  of  the  patient  and  a  twelve-hour  airing  of 
the  room  and  its  contents  are  sufficient  protection  to  sus- 
ceptible persons. 

Second  and  even  third  attacks  of  measles  are  more  com- 
mon than  in  the  case  of  any  other  contagious  disease.  The 
great  fatality  of  measles  among  the  natives  of  islands  in 
which  the  disease  is  not  indigenous  is  well  known,  as  seen 
in  Fiji,  where  over  a  quarter  of  the  population  died  in  four 
months  from  this  disease,  and  in  the  Faroe  Islands. 

MUMPS 

This  disease  is  generally  made  light  of  by  everybody  ex- 
cept the  patient.  It  differs  from  the  other  contagious  dis- 
eases in  having  a  long  period  of  development — fourteen  to 
twenty-four  days,  more  usually  about  three  weeks.  Rarely 
the  first  symptoms  have  not  shown  themselves  for  thirty- 
six  to  forty-two  days  after  exposure.  Patients  may  give 
the  disease  to  others  for  a  few  days  before  they  become 
sick,  and  afterward  for  two  to  four  weeks  from  the  begin- 
ning, of  their  sickness,  so  that  it  is  safer  to  isolate  children 


102  THE   PREVENTION  OP  DISEASE 

for  at  least  three  weeks.  As  adult  males  are  apt  to  have 
painful  swelling  of  the  testicles  as  a  complication  of  mumps 
unless  they  keep  quiet,  they  should  stay  in  bed  during  the 
height  of  mumps  and  remain  in  the  house  for  ten  days. 
The  pain  and  swelling  in  the  region  under  and  in  front  of 
the  ears,  which  constitutes  mumps,  usually  lasts  for  a  week 
or  ten  days. 

Disinfection  of  the  sick  room  and  its  contents  is  not  prac- 
tised in  mumps  because  the  disease  appears  to  be  acquired 
by  direct  contact  with  a  patient,  and  not  with  clothing  and 
inanimate  objects  which  may  have  been  exposed  to  the 
sick.  The  disease  is  very  rarely  fatal,  and  then  through 
some  complication. 

WHOOPING-COUGH 

The  public  needs  instruction  concerning  the  prevention 
of  whooping-cough  more  than  in  any  other  contagious 
disease.  This  follows,  first,  because  less  pains  are  taken 
to  isolate  patients  than  in  the  case  of  any  other  of  the  in- 
fectious disorders,  and,  second,  because  both  the  laity  and 
profession  appear  to  think  and  act  as  though  whooping- 
cough  were  a  mild  and  comparatively  inconsequential 
disease. 

As  a  matter  of  fact,  whooping-cough  is  more  fatal  than 
either  measles,  scarlet  fever,  or  diphtheria,  if  we  include 
its  complications,  in  children  under  five  years  of  age.  Nine 
out  of  every  ten  deaths  from  whooping-cough  are  due  to 
pneumonia,  and  the  severe  coughing  occasionally  leads  to 
death  from  bleeding  into  the  brain  (apoplexy)  and  starva- 
tion from  vomiting,  while  deaths  from  heart  failure  and 
convulsions  are  not  uncommon.  Parents  are  shamefully 
responsible  for  permitting  their  children,  suffering  from 
whooping-cough,  to  play  with  other  healthy  young  people. 
The  reason  this  lapse  is  more  frequent  and  possible  than  in 


WHOOPING-COUGH  103 

the  case  of  other  contagious  diseases  is  that  patients  with 
whooping-cough  are  usually  about  and  outdoors. 

The  whooping-cough  germ  has  only  recently  been  dis- 
covered and  isolated.  It  appears  to  live  in  the  mucus  in 
the  air-passages,  where  it  may  be  found  during  the  first 
few  weeks  of  the  disease.  Precisely  how  long  it  may  exist 
in  the  patient  is  not  certain,  but  it  apparently  is  not  carried 
by  healthy  persons  from  the  sick  to  the  well,  and  there  are 
no-  "carriers,"  as  in  the  case  of  diphtheria,  meningitis,  etc. 
One  attack  protects  an  individual  from  another.  Almost 
every  one  is  susceptible  and  has  the  disease  at  some  period 
of  life.  One-half  the  cases  are  under  six  years  of  age,  but 
infants  under  six  months  are  not  so  liable  to  the  disease. 
There  are  about  10,000  deaths  a  year  from  whooping- 
cough,  on  the  average,  in  the  United  States,  and  the  death- 
rate  is  5  to  15  in  100. 

After  exposure  one  to  two  weeks  elapse  before  the 
symptoms  begin.  If  more  than  two  weeks  pass  after 
exposure  without  development  of  the  disease  there  is  little 
danger  of  its  occurrence.  Whooping-cough  starts  Jike  an 
ordinary  cold  and  cough,  although  the  cough  is  more  con- 
stant than  usual  at  night.  Unless  whooping-cough  is 
prevalent  it  is  not  possible  to  make  a  diagnosis  until  the 
second  stage  begins,  after  one  or  two  weeks  more.  Then 
there  are  severe  spells  of  coughing,  four  to  twenty  or  more 
daily. 

The  child  in  one  of  these  gives  fifteen  or  twenty  short 
coughs,  grows  blue,  and  appears  to  be  suffocating,  and  then 
draws  a  long  breath  with  a  crowing  sound  (the  whoop), 
and  often  ends  by  vomiting.  The  whooping  stage  may 
last  an  uncertain  number  of  weeks.  While  children  are 
best  kept  outdoors  with  the  disease,  they  should  not  be 
permitted  to  play  with  well  children  until  after  six  weeks 
and  after  all  whooping  and  coughing  of  phlegm  has  ceased. 


104  THE    PREVENTION    OF   DISEASE 

They  should  have  a  separate  room  to  sleep  in,  and  all 
material  which  is  vomited  or  coughed  up  should  be  burned 
at  once.  Paper  napkins  and  old  clean  cloths  may  be  used 
for  collecting  secretions  from  the  nose  and  mouth.  While 
direct  contact  with  the  sick  is  usually  the  cause  of  con- 
tagion, yet  the  germs  may  be  sprayed  into  the  air  in  cough- 
ing and  be  carried  about  on  clothing.  There  is  a  classical 
case  in  which  clothing  from  a  patient  on  a  ship  in  St. 
Helena  conveyed  the  disease  to  the  children  of  a  laundress 
on  shore. 

Quite  recently  a  vaccine  has  been  used  made  in  much 
the  same  way  as  described  for  use  in  typhoid  fever ;  that  is, 
consisting  of  the  dead  germs  of  whooping-cough  and  in- 
jected under  the  skin.  This  appears  to  be  of  considerable 
value  in  protecting  those  exposed  to  whooping-cough  from 
taking  the  disease.  Hess  (1914)  reports  that  with  the 
use  of  vaccine  protection,  in  an  epidemic  of  whooping- 
cough,  1  in  12  took  the  disease,  while  without  it  almost  3 
out  of  4  children  became  sick  with  the  disorder. 

It  is  without  danger  and  should  be  tried.  The  New 
York  Health  Department  has  ardently  advocated  vaccina- 
tion against  whooping-cough. 

Disinfection  of  the  room  should  be  done  after  the 
patient  has  recovered.  The  chief  danger  of  pneumonia  is 
during  early  convalescence. 

PLAGUE.     BUBONIC  PLAGUE 

Plague  has  been  known  from  the  second  century,  and  in 
the  fourteenth  it  destroyed  one-fourth  of  the  people  of 
Europe,  and  was  known  as  the  "black  death."  It  ravaged 
Europe  again  in  the  seventeenth  century,  but  gradually 
died  down,  until  it  appeared  again  in  Hong  Kong  in  1894. 

There  have  been  enormous  losses  from  plague  in  India, 
some  five  and  one-half  millions  dying  of  it  in  the  United 


PLAGUE.       BUBONIC    PLAGUE  105 

Provinces,  Bombay,  and  the  Punjab  between  1896  and 
1911.  Since  that  time  the  disease  has  occurred  in  the 
Far  East,  in  Persia,  Turkey  in  Asia,  Java  and  Sumatra, 
and  in  Egypt  and  Japan. 

There  have  been  a  few  cases  in  England  and  the  United 
States  within  the  past  few  years,  notably  in  San  Francisco 
(121  cases  in  1907-08),  and  a  few  cases  in  Seattle,  and  at 
the  present  writing  (1914)  an  outbreak  has  just  started  in 
New  Orleans.  With  the  modern  manner  of  handling  the 
disease  in  the  most  civilized  communities  there  appears 
to  be  little  danger  of  a  large  epidemic  of  the  disease. 

Several  forms  of  the  disease  occur.  The  most  common 
begins  with  fever,  headache,  pain  in  the  back  and  stiffness 
of  the  limbs,  and  enlarged  glands  (buboes),  especially  in 
the  groins,  appear  from  the  third  to  fifth  day.  Some 
patients  are  so  overwhelmed  by  the  germs  that  they  die 
within  three  days  before  the  buboes  form,  and  in  the  pneu- 
monic type  the  disease  is  evidenced  by  a  rapidly  fatal  form 
of  inflammation  of  the  lungs. 

Plague  is  contagious  in  less  than  3  per  cent,  of  cases,  and 
the  contagion  is  seen  only  in  the  pneumonia  cases  crowded 
together  in  unsanitary  conditions. 

Bubonic  plague  is  transmitted  to  man  from  rats  and 
ground  squirrels  entirely  by  rat-  or  squirrel-fleas,  and  from 
rat  to  rat  or  squirrel  to  squirrel  by  the  same  insect.  The 
disease  is  carried  from  place  to  place  by  rat-fleas  on  persons 
or  their  belongings.  The  rat-fleas  may  live  a  week  when 
starved,  but  on  human  beings  they  may  subsist  three  or 
four  weeks.  Rat-fleas  do  not  naturally  take  to  humans  or 
other  animals,  and  it  is  only  when  they  are  starved  that 
they  change  their  habitat,  except  in  the  case  of  ground 
squirrels,  chipmunks,  and  a  few  other  animals. 

A  single  rat-flea  may  harbor  as  many  as  500  plague  germs 
in  its  body,  and  human  epidemics  usually  follow  severe 


106  THE   PREVENTION   OF   DISEASE 

outbreaks  in  rats,  as  the  terrible  mortality  in  rats  drives 
their  fleas  to  the  human  host. 

The  cat-  and  dog-flea  are  apparently  not  invaded  by  the 
plague  germ  and  so  are  not  dangerous  to  man.  On  the 
contrary,  in  the  Punjab  it  has  been  shown  that  where  there 
are  from  30  to  75  cats  for  every  100  houses,  there  is  no 
plague,  owing  to  the  destruction  of  rats,  and  this  method 
of  fighting  plague  is  prescribed  by  the  scriptures  of  the 
Mohammedans  and  Hindus. 

The  modern  way  of  fighting  plague  consists  in  poisoning 
and  trapping  rats  and  examining  dead  rats  for  plague 
germs,  in  disposal  of  food  and  garbage  in  rat-tight  vessels, 
general  cleansing  and  destruction  of  shacks,  out-houses, 
and  stables  affording  nests  for  rats,  but  particularly  en- 
forcement of  rat-proof  buildings,  to  make  life  impossible  to 
rats  through  starvation.  These  measures  have  been  splen- 
didly carried  out  in  the  United  States  through  the  agency 
of  the  Public  Health  Service,  often  hampered  as  much  as 
possible  by  the  state  and  municipal  lay  authorities  who 
were  most  concerned,  as  in  California  and  Seattle.  The 
appearance  of  dead  rats  in  a  seaport  should  immediately 
excite  suspicion,  and  cultures  from  their  bodies  will  decide 
the  existence  of  plague  germs,  together  with  inoculation 
of  guinea-pigs.  Segregation  of  the  sick,  fumigation  with 
sulphur  of  ihe  premises  and  ships  to  destroy  rats  and  fleas, 
and  shields  on  the  hawsers  to  prevent  rats  from  boarding 
ships  are  essential.  To  protect  individuals  against  plague 
there  is  Haffkine's  vaccine,  consisting  of  the  dead  bodies  of 
the  plague  germs  and  harmless  in  itself.  One  injection 
of  this  reduces  the  chances  of  getting  the  disease  four-fifths, 
while  those  who  have  had  the  injection  and  acquire  the 
disease  have  two  and  one-half  times  the  expectation  of 
recovery  as  compared  to  the  uninoculated  (Martin). 


CHAPTER  V 

GERM  DISEASES  ONLY  COMMUNICATED  BY  THE 
BITES  OF  MOSQUITOES 

Malaria,  Yellow  Fever,  Dengue 
MALARIA 

MALARIA  is  now  known  to  be  due  to  animal  parasites 
(plasmodia)  which  are  only  transmitted  to  man  by  a  par- 
ticular kind  of  mosquito,  the  genus  Anopheles,  eight  species 
of  which  act  as  hosts  to  plasmodia.  The  mosquitoes,  in 


©        6  c 

Fig.  1. — Various  mosquitoes  in  attitudes  of  repose:  a,  Culex  pip- 
iens  or  common  mosquito;  b,  Myzorrhynchus  pseudopictus;  c, 
Anopheles  maculipennis  or  malarial  mosquito  (Manson). 

their  turn,  get  the  malarial  parasite  into  their  bodies  by 
biting  a  person  who  has  the  malarial  parasites  in  his 
blood.  Therefore  the  prevention  of  malaria  may  be 
summed  up,  first,  in  destroying  mosquitoes;  second,  in 

107 


108  THE   PREVENTION   OF   DISEASE 

avoiding  mosquito  bites;  third,  in  taking  quinin  to  kill 
the  parasites  in  the  body.  In  the  avoidance  of  mosquito 
bites  the  individual  is  protected  against  malaria  and  the 
community  also,  because  only  in  this  way  do  the  mosqui- 
toes become  dangerous.  Thus,  malaria  was  practically 
unknown  about  Boston  some  years  ago,  but  the  advent 
of  Italians,  who  were  employed  in  large  numbers  in  the 
Metropolitan  Sewage  System,  introduced  malaria  to  the 
region  by  infecting  mosquitoes  which  had  previously  been 
harmless.  The  disease  thus  became  indigenous  in  the 
neighborhood. 

The  female  mosquito  lays  about  100  eggs  on  the  surface 
of  fresh  water,  and  preferably  in  the  presence  of  grass  and 
scum  of  algae.  After  eight  days  the  insect  becomes  full- 
grown,  does  not  fly  great  distances,  and  avoids  wind,  but 
seeks  protection  in  grass,  undergrowth,  and  brush. 

The  greatest  danger  threatens  from  mosquitoes  bred 
within  300  feet  of  a  house,  although  they  may  fly  much 
greater  distances.  Within  this  area,  at  any  rate,  all 
agencies  favoring  the  breeding  of  mosquitoes  should  be 
abolished.  Tall  weeds,  shrubs,  grass,  and  undergrowth 
of  all  kinds  should  be  gotten  rid  of,  and  trees  near  the 
house  are  also  inadvisable  in  a  malarial  region.  Collec- 
tions of  stagnant  water  are  particularly  dangerous.  Thus, 
disused  wells,  springs,  empty  cans,  bottles,  watering 
troughs  for  animals,  roof-gutters,  rain-water  barrels,  or 
depressions  in  the  soil,  or  even  in  the  hollow  of  leaves, 
where  water  may  stand  a  week,  are  prolific  breeding  places. 

The  water  should  be  changed  in  these  places  daily,  or 
the  receptacles  should  be  screened,  or  kerosene  may  be 
kept  on  the  surface  of  standing  water,  or  the  collections  of 
water  should  be  gotten  rid  of.  One  ounce  of  kerosene  will 
cover  15  square  feet  of  water.  A  constant  drip  from  a 
partly  opened  stop-cock  of  a  can  is  the  best  method  of 


MALARIA  109 

application.  Brooks  should  be  kept  clear  of  weeds,  so 
that  there  may  be  no  standing  water,  and  ponds  should  be 
covered  with  petroleum,  drained  away,  or  stocked  with 
various  kinds  of  minnows.  The  filling  in  or  drainage  of 
marshes  are  essential. 

Mosquito  bites  may  be  avoided  by  staying  in  a  screened 
house  except  during  the  hours  between  sunrise  and  sun- 
set. In  case  this  is  not  practicable  the  head  should  be 
protected  by  a  head  net,  the  hands  and  wrists  by  gauntlets, 
and  the  ankles  by  leggings,  especially  in  the  tropics. 

The  house  should  be  absolutely  screened  with  wire 
netting  of  No.  16  mesh.  In  the  tropics  the  bed  should 
also  be  protected  by  a  special  netting,  as  described  under 
Yellow  Fever.  In  sitting  after  dark,  women  should  cover 
their  ankles  with  high  shoes  and  their  necks  with  scarfs. 
A  bedroom  well  off  the  ground  is  safer  from  mosquitoes. 

Where  there  are  many  mosquitoes  in  a  room  they  may  be 
killed  by  burning  broken  pieces  of  roll  sulphur  in  a  deep 
pan  placed  on  bricks  on  sand,  or  inside  a  larger  pan,  to 
avoid  setting  fire  to  the  premises. 

Cracks  about  doors  and  windows  should  be  made  tight 
by  pasting  strips  of  paper  over  them. 

In  a  reasonably  well-built  house  this  is  unnecessary. 
Three  pounds  of  sulphur  are  suitable  for  a  room  10  by  10 
by  10  feet.  Eight  ounces  of  wood  alcohol  are  poured 
on  the  sulphur  and  ignited,  and  the  door  of  the  room  is 
closed  at  once  and  not  opened  for  twelve  hours. 

A  word  may  be  said  about  screening  houses.  Where  the 
inmates  sit  outside  after  sunset  the  veranda  must  be 
wholly  screened.  Mosquitoes  are  only  active  during  the 
night,  and  will  enter  a  house  through  the  smallest  crevices, 
such  as  keyholes  and  chimneys.  These  must  be  stopped  by 
wads  of  paper  placed  in  the  throats  of  chimneys,  in  fire- 
places, and  in  keyholes.  If  the  smallest  holes  are  not 


110  THE    PREVENTION    OF   DISEASE 

stopped  a  house  will  act  as  a  trap  for  mosquitoes,  who  may 
enter  but  not  find  their  way  out.  Wire  screens  should 
cover  every  door  and  window  in  the  house  which  may  be 
opened. 

Window  screens  should  not  be  movable,  but  the  frames 
should  fit  tightly  against  the  lower  part  of  the  upper  sash 
and  be  fastened  by  screws.  The  upper  sash  must  not  be 
opened.  The  netting  should  not  be  larger  than  a  No.  18 
for  the  yellow-fever  mosquito  nor  larger  than  a  No.  16  for 
the  malarial  mosquito.  The  number  means  the  number  of 
meshes  to  the  inch,  A  coat  of  thin  paint  will  convert  No. 
14  into  No.  16  mesh. 

The  taking  of  quinin  to  kill  parasites  in  the  body  is  the 
most  practical  measure  of  all,  although  not  so  useful  as 
thorough  screening,  together  with  the  taking  of  quinin. 
Thus,  in  Italy,  where  quinin  is  supplied  free  of  cost  to  the 
poorer  part  of  the  population,  the  inroads  of  malaria  have 
been  tremendously  reduced  by  daily  consumption  of 
quinin.  Celli  reports  that  the  mortality  from  malaria  has 
there  been  lowered  75  per  cent.,  and  in  the  malarial  region 
about  Rome  the  number  of  annual  cases  has  been  reduced 
from  11,653  to  2974  by  this  means. 

In  our  farming  population,  where  elaborate  methods  of 
screening  and  draining  are  not  practicable,  the  daily  use  of 
quinin  is  the  most  satisfactory  method  of  preventing  ma- 
laria. Quinin  does  not,  however,  always  kill  all  the 
malarial  parasites  in  the  blood,  because  in  some  persons 
the  parasites  may  still  exist,  but  the  quinin  keeps  down 
their  numbers  sufficiently  to  prevent  an  attack,  and  the 
individual  may  feel  perfectly  well,  the  disease  remaining 
latent  in  his  system.  No  harm  is  done  by  taking  the  neces- 
sary preventive  amount  of  quinin  daily  the  year  round,  as 
was  shown  by  the  higher  officials  at  Panama,  who  took 
2  grains  three  times  daily  at  each  meal.  In  some  persons 


MALARIA  111 

this  dose  may  cause  buzzing  in  the  ears  and  discomfort, 
but  this  usually  wears  off  within  a  week. 

Quinin  might  only  be  taken  during  the  mosquito  season, 
but  in  case  of  persons  who  have  had  malaria  the  parasites 
may  remain  in  sufficient  numbers  in  the  blood  to  produce 
an  attack  of  fever  before  they  are  again  bitten  by  mosqui- 
toes the  following  summer.  Such  persons  should  begin  to 
take  quinin  in  March,  and  other  persons  should  start  to 
take  it  in  June  and  continue  it  daily  to  November  in  this 
country.  In  the  tropics  it  is  necessary  to  take  quinin  the 
year  round.  The  dose  for  adults  should  be  2  grains  of 
quinin  sulphate  in  capsules  with  each  meal  three  times 
daily.  For  children  under  ten,  5  grains  of  the  tannate  of 
quinin  in  chocolate  tablets  are  given  thrice  daily.  This 
form  of  quinin  does  not  contain  half  as  much  of  the  drug 
as  the  sulphate,  and  hence  the  larger  dose.  In  children 
under  five,  2-grain  tablets  three  times  daily  will  suffice. 
While  capsules  of  quinin  are  the  most  soluble  containers 
and  preferable,  yet, » where  the  cost  is  important,  quinin 
sulphate  may  be  bought  much  more  cheaply  by  the 
hundred  in  tablets.  If  these  are  properly  made,  they 
should  begin  to  crumble  in  a  glass  of  water  within  ten 
minutes.  In  this  case  they  are  suitable  for  use.  The 
only  objection  to  pills  or  tablets  of  quinin  is  that  they  are 
frequently  so  insoluble  that  they  pass  through  and  out  of 
the  intestines  just  as  they  were  swallowed.  In  tropical 
countries,  where  malaria  is  severe,  it  is  advisable  to  take 
more  than  6  grains  daily  if  it  can  be  done  without  much 
discomfort.  Thus,  3  grains  should  be  taken  three  times 
daily,  or  even  10  grains  daily  is  safer. 

A  patient  suffering  from  malarial  fever  should  be  es- 
pecially well  protected  by  mosquito  screening  to  prevent 
infection  of  mosquitoes  which  might  bite  him  and  thus 
transmit  the  disease  to  others.  For  this  reason  white 


112          .  THE   PREVENTION    OF   DISEASE 

persons  avoid  the  neighborhood  of  the  native  quarters  in 
the  tropics,  as  the  mosquitoes  are  more  apt  to  be  infected 
there. 

Of  course,  the  precautions  against  malaria  are  only 
required  in  regions  in  which  the  disease  exists;  that  is,  in 
which  the  mosquitoes  are  infected  with  it.  The  disease  is 
prevalent  in  many  parts  of  the  South  and  in  the  central 
Atlantic  states,  especially  in  the  fall.  In  the  northwestern 
states  and  on  the  northern  Pacific  coast  it  is  unknown. 

Malaria  occurs  in  some  places  throughout  New  England, 
but  is  much  less  common  about  New  York  City  and 
Philadelphia  than  formerly.  The  disease  is  only  found  in 
the  Great  Lake  region  about  Lake  Erie  and  St.  Clair. 

YELLOW  FEVER 

The  prevention  of  yellow  fever  is  the  most  interesting  of 
any  similar  attempt  in  the  history  of  medicine,  on  account 
of  the  heroism  involved,  the  ingenuity  practised,  and  the 
wonderful  success  attained.  Yellow  fever  has  been  shown 
not  to  be  contagious  through  contact  with  a  patient,  his 
surroundings,  or  discharges,  but  to  be  only  transmitted 
through  the  medium  of  a  certain  species  of  mosquito,  the 
Stegomyia  fasciata.  The  great  discovery  was  made  in 
Cuba  by  United  States  Army  surgeons  in  1900  following  the 
American  occupation.  As  early  as  1881  Dr.  Carlos  Finlay 
of  Havana  had  suggested  that  yellow  fever  was  due  to 
mosquito  bites,  and  the  work  of  Dr.  Ross  in  India  had 
proved  that  malaria  was  only  caused  by  the  bites  of  mos- 
quitoes, and  these  facts  and  theories  stimulated  the 
American  Commission  to  experiment  in  regard  to  yellow 
fever.  This  body  was  made  up  of  the  following  United 
States  Army  surgeons — Drs.  Walter  Reed,  Carroll, 
Lazear,  and  Agramonte.  The  experiments  were  done  at 
Camp  Lazear  in  Cuba,  in  a  frame  house  with  a  screened 


YELLOW    FEVER  113 

vestibule,  and  so  constructed  as  to  shut  out  sunlight  and 
fresh  air.  Previous  to  this  time,  in  September,  Dr.  Lazear 
had  permitted  himself  to  be  bitten  by  a  mosquito  in  a 
yellow-fever  ward  and  he  sickened  in  five  days  and  died  a 
week  later  of  the  disease.  Two  months  later  fifteen 
mosquitoes  which  had  bitten  yellow  fever  patients  were 
allowed  to  bite  one  of  the  volunteers  at  camp  Lazear,  and 
he  became  ill  with  the  disease  five  days  later,  while  two 
other  susceptible  persons  slept  in  the  same  room  for  eight- 
een nights  separated  only  by  a  mosquito  screened  partition 
from  the  patient.  These  latter  remained  perfectly  well. 
Many  other  volunteers  knowingly  permitted  themselves 
to  be  bitten  by  mosquitoes  (which  had  bitten  yellow  fever 
patients  a  sufficient  time  previously)  and  they  all  took  the 
disease.  To  prove  that  there  was  no  danger  of  contagion 
from  the  clothes  or  discharges  of  yellow  fever  patients,  two 
soldiers  and  a  surgeon  slept  for  twenty-one  consecutive 
nights  in  a  mosquito-screened  house  in  which  were  boxes 
containing  clothing  of  yellow  fever  patients  soiled  with 
their  blood,  urine,  and  bowel  discharges.  Each  night  the 
men  handled  these  by  unpacking  them  and  hanging  them 
on  a  line  in  the  room,  and  each  morning  they  packed  them 
up  again  in  the  box.  Moreover,  two  other  soldiers  slept 
twenty-one  days  in  the  night-clothes  and  sheets  just  as 
they  had  been  taken  from  patients  recently  dying  from 
yellow  fever,  and  one  of  these  men  actually  slept  on  a  towel 
soiled  with  the  blood  of  a  yellow-fever  patient.  None  of 
these  volunteers  took  the  disease.  The  outcome  of  all 
these  experiments  proved:  (1)  That  yellow  fever  was  only 
transmitted  by  the  bites  of  a  certain  species  of  mosquito. 
(2)  That  the  mosquito  is  harmless  for  a  period  of  twelve 
days  or  longer  after  biting  a  yellow  fever  patient,  but  that 
then  the  mosquito  is  dangerous  to  man  as  long  as  it  lives, 
in  one  case  fifty-seven  days  following  the  biting  of  a  patient. 


114  THE   PREVENTION   OP  DISEASE 

(3)  That  a  period  of  three  to  five  days  after  a  person  is 
bitten  by  a  mosquito,  which  has  previously  bitten  a  yel- 
low fever  patient,  must  elapse  before  the  patient  begins  to 
sicken.  (4)  That  the  injection  into  a  susceptible  person 
of  even  8  drops  of  blood  taken  from  a  yellow  fever 
patient  in  the  first  or  second  days  of  his  sickness  will  pro- 
duce the  disease  in  one  who  has  not  previously  had  it.  (5) 
That  the  mosquito  to  be  dangerous  must  bite  a  patient 
during  the  first  three  days  of  his  sickness.  (6)  That  there 
is  no  danger  from  contact  with  a  patient,  his  clothing  or 
discharges,  but  only  from  mosquitoes  which  have  bitten 
patients. 

Owing  to  this  knowledge  that  hotbed  of  infection, 
Havana,  which  had  been  a  pest-hole  of  yellow  fever  for 
130  years  was  cleared  of  the  disease  by  Col.  Gorgas  in  1901 
by  interfering  with  the  breeding  of  mosquitoes,  by  destroy- 
ing mosquitoes  which  had  bitten  yellow  fever  patients,  and 
by  preventing  mosquitoes  from  biting  patients.  So,  again, 
in  Panama  Col.  Gorgas  stamped  out  the  disease  absolutely 
within  sixteen  months  of  the  American  occupation  in  1904, 
with  no  return  since,  and  upon  this  result  has  the  success 
of  the  canal  construction  largely  depended. 

Yellow  fever  is  indigenous  in  Vera  Cruz,  Rio,  and 
Spanish- American  ports;  it  appears  periodically  in  tropical 
Atlantic  ports  of  America  and  Africa,  and  occasionally 
between  the  15th  and  35th  parallels  of  north  latitude. 
Where  it  is  prevalent  the  taking  of  the  temperature  on  the 
slightest  feeling  of  illness  will  arouse  the  first  suspicion  of 
the  disease  if  there  is  fever.  The  disease  begins  in  a  person 
who  has  been  bitten  three  to  five  days  before  by  a  particu- 
lar kind  of  mosquito,  which  has  itself  bitten  a  yellow 
fever  patient  some  twelve  or  more  days  previously. 

Yellow  fever  starts,  like  many  another  fever,  with  head- 
ache, pain  in  the  back  and  limbs,  nausea,  and  vomiting. 


DENGUE,    BREAKBONE    FEVER,    DANDY    FEVER        115 

The  peculiar  features  of  the  disease  begin  on  the  second 
day,  with  tenderness  over  the  stomach,  and  the  whites  of 
the  eyeballs  begin  to  grow  yellow  with  jaundice,  while  the 
gums  are  spongy  and  blood  may  be  squeezed  from  them. 

To  personally  avoid  the  disease,  one  should  only  go  out- 
doors in  well-lighted  places  (the  Stegomyia  may  frequent 
darkened  woods)  between  the  hours  of  9  A.  M.  and  3  p.  M., 
as  the  mosquitoes  are  not  active  during  this  period.  After 
3  P.  M.  one  should  either  seek  elevations,  where  there  are 
no  mosquitoes,  or  remain  in  a  thoroughly  mosquito- 
screened  veranda  or  room  and  sleep  in  a  room  high  above 
the  ground  under  a  mosquito  bar. 

Mosquitoes  already  in  a  room  should  be  killed  by  fumi- 
gation with  sulphur,  as  advised  under  Malaria.  If  it  is 
essential  to  be  outdoors  in  the  evening  one  should  wear 
head  nets,  gauntlets,  and  leggings. 

Screening  of  the  house  is  even  more  important  than  in 
the  case  of  malaria,  where  the  method  is  described.  A 
mosquito  bar  for  beds  should  be  made  of  fine  bobinet, 
hung  from  an  oblong  frame  above  the  bed. 

The  frame  is  better  a  little  higher  than  the  bed,  and  may 
be  made  by  tying  upright  posts  to  the  bed-posts  and  run- 
ning, a  cord  about  the  top  of  these  on  which  the  net  is  hung. 
It  should  not  be  slit  on  the  side,  but  be  made  of  one  piece, 
which  should  hang  from  the  inside  of  the  frame,  so  as  not 
to  be  interfered  with  by  the  posts,  and  be  tucked  in  at  the 
head,  foot,  and  sides  of  the  bed  at  night  and  also  by  day. 

The  beds  should  be  three-quarters  size,  because  if  one's 
body  projects  against  the  mosquito  net  in  narrow  beds  a 
mosquito  may  bite  through  the  net. 

DENGUE,  BREAKBONE  FEVER,  DANDY  FEVER 

Dengue  is  transmitted  from  one  individual  to  another  by 
a  special  mosquito  (Culex  fatigans),  and  this  is  the  only 


116  THE    PREVENTION    OF   DISEASE 

known  method  of  communication,  as  it  is  not  contagious 
in  the  ordinary  sense.  The  special  germ  which  is  the  cause 
of  the  disease  has  not  yet  been  certainly  identified.  The 
disease  occurs  in  tropical  and  subtropical  countries,  as  in 
India,  China,  and  the  Philippines,  and  in  our  Southern 
States,  as  far  north  as  Virginia.  Except  in  the  tropics,  it 
always  appears  during  the  warm  season.  Dengue  attacks 
a  large  part  of  the  population,  and  when  the  writer  was  a 
youth  he  acted  as  understudy  for  the  medical  profession  in 
St.  Augustine  in  carrying  about  medicine  and  advice  for 
the  doctors  who  were  bedridden,  together  with  everybody 
else,  during  an  outbreak. 

Three  to  five  days  after  exposure  the  patient  comes  down 
with  high  fever,  chilliness,  and  excruciating  pains  in  the 
head,  back,  legs,  and  joints,  especially  the  knees.  These 
symptoms  continue  for  three  or  four  days,  and  then  the 
fever  departs  for  two  to  four  days,  only  to  reappear  again 
for  a  few  days  longer,  although  the  disease  does  not  usually 
last  much  more  than  a  week. .  Various  eruptions  are  usu- 
ally present,  and  there  may  or  may  not  be  swelling  in  the 
painful  joints. 

The  writer  attributed  his  escape  from  dengue  to  previous 
dosage  with  10  grains  of  quinin  daily,  but  this  means  of 
prevention  is  denied  by  some  of  the  leading  medical  author- 
ities. The  only  known  opportunity  of  escape  is  by  avoid- 
ing all  mosquito  bites  by  means  suggested  under  Malaria 
and  Yellow  Fever.  Fortunately,  while  dengue  is  exceed- 
ingly painful  it  is  not  a  fatal  disease. 


CHAPTER  VI 

GERM  DISEASES  (Continued) 

Tuberculosis,  Colds,  Influenza,  Cerebrospinal  Meningitis,  Infantile 

Paralysis 

TUBERCULOSIS 

TUBERCULOSIS  is  the  chief  destroyer  of  the  human  race. 
Yet  the  deaths  from  it  are  steadily  declining;  so  much  so, 
that  while  it  has  been  estimated  that  one-fourth  of  all 
deaths  in  Europe  in  the  last  century  were  due  to  the  dis- 
ease, at  the  present  time  it  produces  but  one-tenth  of  all 
deaths  in  the  most  enlightened  communities. 

This  result  has  been  accomplished  by  methods  of  pre- 
vention, depending  upon  our  increasing  knowledge  of  the 
disease  and  the  various  means  by  which  persons  become 
infected.  Our  exact  knowledge  of  the  contagiousness  of 
tuberculosis  dates  from  the  discovery  of  Koch  (in  1882) 
that  it  is  caused  by  a  special  germ ;  in  fact,  this  epoch  marks 
the  beginning  of  our  knowledge  of  germ  diseases,  since  the 
germ  of  consumption  was  the  first  to  be  thoroughly  studied 
and  proved  to  be  the  one  and  sole  cause  of  tuberculosis. 

There  are  some  astonishing  facts  which  we  must  first 
consider  before  we  can  have  a  rational  conception  of  the 
disease.  While  the  name  "tuberculosis"  strikes  terror  in 
those  afflicted  with  it,  yet  the  really  important  matter  is 
not  so  much  whether  one  has  tuberculosis  as  whether  one 
has  it  in  a  serious  or  active  form.  Or,  in  other  words, 
whether  the  disease  is  in  an  active  state,  or  whether 

117 


118  THE   PREVENTION   OF  DISEASE 

it  is  inactive  or  healed.  Now  for  the  facts:  Over  90 
per  cent,  of  city  dwellers  show  signs  of  tuberculosis  in  their 
bodies  after  death  from  any  cause;  60  per  cent,  show  signs 
in  the  lungs.  The  tuberculin  test,  which  is  used  in  living 
patients,  is  so  delicate  that  it  will  not  only  show  active 
and  serious  tuberculosis,  but  the  presence  of  minute  and 
even  practically  healed  small,  diseased  areas  in  any  part  of 
the  body.  By  this  test  90  per  cent,  of  all  children  are 
proved  to  be  tuberculous  by'  the  age  of  twelve,  and  60  per 
cent,  of  healthy  young  adults.  If  the  whole  population 
of  city  and  country  are  considered,  it  is  estimated  that 
from  50  to  70  per  cent,  are  tuberculous  in  some  degree. 
It  will  thus  be  seen  that  while  1  in  every  10  persons  dies 
of  tuberculosis,  8  in  every  10  become  infected  with  the 
disease  and  recover — in  most  cases  the  disease  being  so 
slight  that  the  patient  is  never  aware  of  any  disturbance 
caused  by  it. 

To  prevent  tuberculosis  one  must  know  how  it  is 
acquired.  The  disease  is  not  directly  inherited  from  either 
parent;  that  is,  the  germ  does  not  pass  from  either  parent 
into  the  embryo  (child)  at  the  time  of  conception.  If  either 
parent  is  tuberculous  the  disease  may  be  communicated  to 
the  child  soon  after  birth.  A  certain  susceptibility  may  be 
inherited  (recent  research  rather  points  to  the  existence 
of  some  immunity  against  the  disease  in  the  offspring  of 
the  tuberculous)  and  a  peculiar  build  may  predispose  to 
consumption.  In  some  families  various  members  suc- 
cumb to  the  disease  at  a  certain  age,  as  from  eighteen  to 
twenty-five.  Among  the  children  of  1000  families  tuber- 
culosis was  found  to  be  10  per  cent,  more  common  in  the 
offspring  of  tuberculous  parents.  This  does  not  neces- 
sarily show  heredity  or  susceptibility,  but  is  what  would 
be  expected  in  the  case  of  children  exposed  to  a  contagious 
disease. 


TUBERCULOSIS  119 

It  is  now  generally  accepted  that  childhood  is  the  age 
at  which  tuberculosis  is  more  frequently  acquired,  al- 
though it  may  lie  dormant  until  adult  life  and  then  become 
active  as  consumption.  The  supposedly  inherited  build 
suggesting  "greater  susceptibility  to  tuberculosis  is  that 
represented  by  pale,  thin,  blond,  delicate-skinned  persons 
with  sloping  shoulders,  projecting  shoulder-blades,  and 
long,  narrow,  and  flat  or  rounded  chests.  It  is  probable 
that  these  persons  are  already  sufficiently  infected  with 
tuberculosis  to  cause  their  inferiority  in  physique. 

Consumption  in  children — that  is,  tuberculosis  of  the 
lungs — is  comparatively  rare.  Tuberculosis  in  them  be- 
gins in  enlarged  glands  of  the  neck,  the  bones  and  joints, 
and  brain.  Ninety-four  per  cent,  of  children  have  en- 
larged glands  in  the  neck  and  80  per  cent,  of  these 
are  tuberculous.  The  germs  enter  the  system  by  three 
paths,  either  through  the  mouth  and  throat,  from  the 
intestines,  or  in  the  air  taken  into  the  lungs.  The  latter 
pathway  was  formerly  thought  the  most  frequent  one, 
but  it  has  been  shown  that  tuberculosis  germs  swallowed 
by  calves  or  injected  into  their  tails  enter  the  blood  and 
may  only  lodge  in  their  lungs  and  not  cause  disease  at  the 
site  of  entrance  into  the  body. 

What  is  the  most  common  path  by  which  the  germs 
enter  the  human  body?  This  is  still  a  debated  point. 

The  germs  arise  from  patients  with  consumption  who 
have  the  disease  in  an  active  form;  that  is,  the  lungs  are 
ulcerating,  and  the  broken-down  tissue,  containing  millions 
of  germs,  is  coughed  up. 

The  germs  soil  the  fingers,  pillow,  handkerchief,  and 
various  objects,  food  and  utensils  handled  by  the  patient, 
and  enter  into  the  dust  of  the  room.  Children  crawling 
around,  placing  all  kinds  of  objects  in  their  mouths  and 
sucking  the  fingers,  toys,  and  other  contaminated  objects, 


120  THE   PREVENTION   OF   DISEASE 

are  thus  apt  to  get  the  germs  into  their  mouths,  which  are 
absorbed  into  the  blood  from  the  mouth  or  digestive  tract. 
Then  there  is  great  danger  from  consumptives  with  germs 
in  their  sputum  (expectoration),  when  one  is  in  close 
proximity  to  them  during  coughing,  from  the  minute 
droplets  sprayed  into  the  air.  Children  run  great  danger 
from  the  milk  of  tuberculous  cows.  This  disease  is  ex- 
tremely frequent  in  cattle — in  some  herds  as  many  as  90 
per  cent,  are  affected;  among  24,000  cows  in  Massachusetts 
50  per  cent,  were  tuberculous,  and  throughout  the  whole 
country  10  per  cent,  of  the  milk  cows  are  tuberculous. 
Taking  at  random  samples  of  mixed  milk  on  the  market  it 
has  been  shown  that  one  in  every  ten  will  contain  the 
germs  of  tuberculosis  and  will  communicate  the  disease  to 
animals.  Even  the  milk  from  certified  herds,  which  are 
tested  for  tuberculosis,  is  not  absolutely  safe,  as  animals 
develop  the  disease  between  testing  times,  and  the  writer 
has  known  of  one  instance  where  20  per  cent,  of  the  animals 
in  a  certified  herd  were  tuberculous  through  carelessness  of 
the  management.  The  most  glaring  example  of  the  danger 
sometimes  inherent  in  the  (apparently)  best  and  cleanest 
milk  which  money  can  buy  is  that  recently  (1915)  brought 
to  light  in  the  case  of  one  of  the  leading  certified  milk  farms 
hi  the  United  States.  In  a  herd  of  over  600  cows  consider- 
ably more  than  one-third  of  this  number  were  suddenly 
found  to  be  tuberculous  by  the  health  authorities  through 
an  accidental  occurrence.  Certified  milk  is  the  best  raw 
milk  procurable  as  a  general  proposition,  but  it  is  far 
from  infallible  in  even  the  protection  against  tuberculosis, 
which  is  the  danger  most  readily  avoidable.  Proper  pas- 
teurization will  make  milk  perfectly  safe.  It  is  estimated 
by  leading  authorities  that  15  per  cent,  of  the  deaths  from 
tuberculosis  in  children  (under  five)  are  due  to  cows'  milk, 
and  that  from  20  to  25  per  cent,  of  all  cases  of  tuberculosis 


TUBERCULOSIS  121 

in  children  arise  from  drinking  cows'  milk.  Milk  causes 
8  per  cent,  of  the  total  deaths  from  tuberculosis  and  kills 
over  10,000  children  annually  in  this  country.  Consump- 
tion or  pulmonary  tuberculosis  is  not  caused  by  the  bovine 
germ,  but  is  always  derived  from  a  human  source,  unless 
the  bovine  germs  become  altered  by  growth  in  the  human 
so  as  to  simulate  the  human  tuberculosis  organism. 

In  children  especially,  diseased  tonsils  lead  to  enlarge- 
ment of  the  glands  in  the  neck,  and  these  are  frequently 
tuberculous,  as  we  have  seen. 

Diseased  tonsils  often  act  as  paths  of  entrance  for  tuber- 
culosis germs,  and  in  100  tonsils  removed  at  Ann  Arbor 
one-fourth  were  found  to  contain  such.  The  average  of  all 
examinations  by  many  doctors  shows  that  only  15  per  cent, 
of  removed  tonsils  are  tuberculous  (Ravenel).  Adenoid 
growths  in  children  (see  page  155)  and  enlarged  tonsils 
both  interfere  with  breathing,  and  thus  favor  consumption 
by  reducing  general  vitality  and  by  interfering  with  the 
proper  ventilation  of  the  lungs. 

To  summarize,  it  may  be  said  that  in  children  the 
greatest  danger  of  tuberculosis  is  from  food,  especially  raw 
milk  and  food  and  other  objects  placed  in  the  mouth, 
infected  by  handling,  by  coughing,  and  by  dust;  while  in 
adults  there  is  more  danger  from  exposure  to  coughing  and 
dust.  That  the  germs  pass  more  often  through  the  mucous 
membrane  of  the  mouth  and  intestines  into  the  blood,  and 
less  often  lodge  in  the  lungs  directly  from  the  air.  That 
consumption  in  adult  life  often  follows  tuberculosis  of  the 
glands  in  children. 

That  infants  and  children  are  most  susceptible,  and 
possibly  the  children  of  tuberculous  parents  possess  less 
resistance  to  the  disease,  but  this  appears  to  be  doubtful. 
That  adults  are  comparatively  insusceptible  to  tubercu- 
losis either  because  they  actually  have  it  in  a  latent 


122  THE    PREVENTION    OF   DISEASE 

form,  or  have  recovered  from  it,  and  they  do  not  retake 
the  disease  (i.  e.,  the  reopening  or  "lighting  up"  of  former 
tuberculosis  or  the  entrance  of  a  fresh  supply  of  tuber- 
culous germs  into  the  body)  unless  through  long  exposure, 
or  circumstances  which  greatly  lower  their  general  vitality 
or  local  resistance,  as  by  the  presence  of  colds,  bronchitis, 
and  influenza.  Consumption  is  never  communicated  to 
attendants  in  well-regulated  hospitals,  and  in  the  case  of 
64  throat  specialists  constantly  exposed  to  the  breath  and 
coughing  of  consumptive  patients  for  years  not  one  devel- 
oped the  disease. 

On  the  other  hand,  when  proper  precautions  are  not 
adopted  the  danger  of  communication  to  adults  living  or 
working  in  the  same  rooms  with  consumptives  is  consider- 
able. This  is  so  well  recognized  that  in  life  insurance  ap- 
plications one  is  asked  if  he  has  lived  or  worked  with  a 
consumptive. 

Thus,  Lampson,  of  Minneapolis  (in  1913),  examined  173 
persons  living  in  33  families,  in  each  of  which  there  was  a 
known  case  of  open  consumption;  that  is,  one  in  which  the 
tuberculous  germs  were  expectorated.  He  found  that  100 
of  these  173  individuals  (exclusive  of  the  known  cases)  also 
showed  evidences  of  tuberculosis,  and  in  all  the  (54)  mem- 
bers of  10  families  signs  of  the  disease  existed.  Whereas,  in 
15  families,  in  which  no  case  of  tuberculosis  was  known  to 
exist,  there  were  80  persons,  and  only  2  of  these  gave  evi- 
dences of  tuberculosis. 

Nevertheless,  the  consensus  of  medical  opinion  is 
that  9  in  every  10  adults  are  immune  to  tuberculosis. 
This  is  based  on  the  fact  that  having  once  had  tubercu- 
losis one  rarely  wholly  recovers.  Small  areas  in  the  body 
contain  living  germs  of  tuberculosis,  and  although  they 
are  enclosed  by  inflammatory  tissue,  yet  the  germs  are 
often  found  circulating  in  the  blood  of  apparently  healthy 


TUBERCULOSIS  123 

persons.  Therefore,  as  9  out  of  10  adults  have  tuber- 
culosis, they  cannot  take  it  again.  An  active  tuberculosis 
in  adult  life  means  a  breaking  down  of  old  latent  trouble. 
An  extra  dose  of  germs  derived  from  exposure  to  a  con- 
sumptive will  rarely  harm  the  adult  already  suffering 
from  a  latent  form  of  the  disease.  The  belief  is  then 
prevalent  among  the  leading  authorities  that  9  in  every 
10  adults  may  be  exposed  to  active  consumption  with 
impunity.  But  a  child,  or  the  tenth  adult  who  has 
not  been,  protected  by  a  previous  mild  tuberculous  in- 
fection from  milk  or  from  human  beings,  will  probably 
have  the  most  fatal  form  on  exposure  to  the  disease — 
as  the  aborigines  succumb  to  it  and  other  contagions. 
Consumption  is  one  of  the  less  severe  forms  of  tubercu- 
losis dependent  upon  a  partial  immunity  existing  in  the 
subject.  This  is  not  a  plea  for  unnecessary  exposure  to 
tuberculosis,  because  an  individual  does  not  usually  know 
whether  he  is  susceptible  or  not,  and  children  must  be 
protected  at  all  costs. 

Certain  occupations  favor  the  incidence  of  tuberculosis. 
Some  of  these  produce  irritation  of  the  membrane  lining 
the  air-passages,  as  the  dusty  trades — stone-cutting,  metal 
grinding,  working  in  wood  and  certain  textiles,  mining. 
Glass-blowers,  cigarmakers,  hat  and  cap  makers,  printers, 
and  bookkeepers  have  been  found  especially  susceptible  to 
the  disease.  While  glass-blowing  may  mechanically  irritate 
the  lungs,  yet  in  many  of  these  occupations  the  chief  harm 
is  done  by  ill-ventilated  quarters,  lack  of  sufficient  space, 
overheating,  overwork,  and  underpay.  Industrial  workers 
constitute  about  one-third  of  the  population,  and  furnish 
about  half  the  deaths  from  tuberculosis  in  this  country, 
and  by  removal  of  the  dust,  through  propeny  controlled 
sanitation  of  factories,  the  number  of  cases  and  deaths 
from  tuberculosis  may  be  reduced  by  one-half,  as  has 


124  THE   PREVENTION    OF   DISEASE 

been  accomplished  in  the  cutlery  industry  in  Germany 
(Kober). 

It  is  thought  that  persons  who  develop  sudden  and  acute 
tuberculosis  late  in  life  are  those  who  have  escaped  the 
disease  in  childhood,  for  with  a  mild  form  of  tuberculosis, 
such  as  most  of  us  have,  one  acquires  a  certain  degree  of 
immunity,  as  in  the  case  of  individuals  recovered  from 
measles  or  scarlet  fever.  In  calves  the  injection  of  small 
doses  of  living,  non-virulent  (human)  tuberculosis  germs 
produces  an  immunity  which  persists  for  an  uncertain 
period.  The  germs  of  tuberculosis  may  live  for  years  in 
an  apparently  healthy  person  and  may  even  be  found 
in  their  blood.  In  healed  areas  in  a  lung  or  gland  the 
germs  become  so  surrounded  by  scar  tissue  that  they 
cause  no  sign  or  symptom  because  they  are  shut  off  from 
the  circulation.  But  let  a  person  become  "run-down" 
and  his  resistance  lowered,  and  partial  immunity  caused 
by  a  mild  infection  with  tuberculosis  in  childhood  no 
longer  protects  him;  the  tissues  about  the  germs  break 
down  and  the  germs  escape  into  the  blood  to  cause  active, 
serious  disease  in  some  part  of  the  body.  In  most  cases 
we  are  wholly  ignorant  of  the  presence  of  tuberculosis  germs 
until  many  years  after  their  entrance  into  our  bodies. 
Every  cause  tending  to  lower  the  general  health — as  dis- 
ease, overwork,  undernourishment,  dissipation,  bad  habits, 
overcrowding,  and  poverty — favor  tuberculosis,  which 
causes  one-third  of  all  deaths  between  the  ages  of  twenty 
and  forty,  the  time  of  greatest  stress  and  strain  from  work 
or  dissipation. 

A  large  portion  of  consumptives  do  not  cough  up  matter 
containing  the  germs  because  the  diseased  area  is  not  con- 
nected with  the  air-tubes  and  is  surrounded  by  a  wall  of 
inflammatory  tissues.  If  there  is  no  expectoration,  or  if 
frequent  examination  of  the  expectoration  shows  that 


TUBERCULOSIS  125 

it  is  free  from  germs,  the  patient  cannot  transmit  the 
disease  to  others  unless  his  condition  changes. 

What  are  the  early  signs  of  tuberculosis  in  adults? 
Loss  of  weight,  loss  of  energy  and  ambition,  and  a  tired 
feeling;  digestive  disturbances;  frequent  and  prolonged 
colds;  pleurisy  or  spitting  of  blood;  pain  about  the  shoul- 
der-blades or  between  the  shoulders;  hacking  or  tickling 
cough  in  the  throat,  hoarseness;  fever  and  night-sweats. 
The  existence  of  one  or  more  of  these  symptoms  should 
cause  the  subject  to  seek  medical  advice. 

A  proper  medical  examination  will  include  taking  tem- 
perature at  two-hour  intervals  for  several  days,  examina- 
tion of  the  expectoration,  if  any,  tuberculin  test  and  re-ray 
examination,  besides  the  ordinary  tapping  on  the  chest  and 
listening  to  the  breath  sounds  with  the  stethoscope.  It  is 
often  impossible  to  make  a  positive  diagnosis  because  the 
symptoms  and  signs  are  indefinite.  The  x-ray  and  tuber- 
culin test  may  indicate  tuberculosis,  and  yet  the  disease 
may  not  be  in  an  active  state. 

But  in  all  doubtful  cases  the  treatment  is  never  doubtful. 
The  same  upbuilding  which  is  most  suitable  in  tubercu- 
losis will  be  indicated  in  debility  from  other  causes. 

Now  in  regard  to  the  preventive  measures  to  be  adopted 
in  the  case  of  children  of  tuberculous  parents.  The  danger 
to  infants  nursing  tuberculous  mothers  is  slight  from  the 
milk,  but  there  is  more  danger  to  the  child  from  soiling  of 
the  breast  and  other  objects  by  the  mother's  fingers,  and 
she  would  very  probably  be  too  much  debilitated  to  under- 
take nursing.  (In  cows  the  milk  is  chiefly  infected  from 
the  germs  in  manure,  which  commonly  contaminate  their 
milk.)  So  that  nursing  a  tuberculous  mother  is  undesir- 
able, and  the  child  should  be  brought  up  as  much  apart 
from  tuberculous  parents  as  possible  and  should  stay  out- 
doors the  greater  part  of  the  time.  A  separate  room  is 


126  THE    PREVENTION   OF   DISEASE 

advisable  for  a  nursery,  with  no  unnecessary  furniture,  cur- 
tains, or  carpet  to  catch  the  dust,  and  every  effort  should 
be  made  to  keep  children  from  placing,  toys,  pencils,  and 
various  objects  in  their  mouths.  \f 

Great  care  should  be  taken  to  wash  their  faces  and  hands 
three  times  daily  before  eating  and  to  brush  their  teeth  at 
least  twice  daily  after  meals.  Separate  eating  and  drink- 
ing utensils,  handkerchiefs,  table,  bed  and  body  linen 
must  be  provided  for  children,  and  all  objects  coming  in 
contact  with  consumptive  parents  or  other  persons  should 
be  avoided.  The  effect  of  crowding  is  seen  in  the  observa- 
tion of  Knopf,  that  42  per  cent,  of  all  cases  of  tuberculosis 
occurred  in  families  living  in  one  room,  while  but  6  per 
cent,  of  all  cases  were  seen  in  families  living  in  four  or  more 
rooms  (Berlin) .  Parents  whose  expectoration  is  filled  with 
tuberculosis  germs  had  better  themselves  be  removed  to  a 
hospital  to  prevent  infection  of  children.  This  applies 
more  especially  to  the  poor.  Advanced  cases  of  consump- 
tion, when  bedridden  and  unable  to  care  for  themselves, 
are  the  chief  source  of  danger  in  spreading  germs  and 
tuberculosis.  What  is  worth  doing  for  animals  is  certainly 
worth  doing  for  children.  It  is  generally  recognized  that 
the  only  way  to  keep  calves  free  from  tuberculosis,  when 
born  of  tuberculous  cows,  is  to  raise  them  in  separate 
barns,  yards,  and  pastures,  and  to  feed  and  water  them 
from  separate  utensils.  In  youth  overstudy  and  over- 
athletic  training  are  equally  harmful,  while  late  hours  and 
the  use  of  alcohol,  tobacco,  and  excesses  of  all  kinds  should 
be  especially  avoided  in  young  adult  life  by  those  who  have 
been  exposed  to  consumptives.  In  case  any  of  the  symp- 
toms noted  above  develop  in  such  individuals  medical 
advice  should  be  sought,  as  these  are  often  premonitory 
of  active  tuberculosis  and  a  change  of  life  at  this  time  is 
usually  sufficient  to  avert  the  disease. 


TUBERCULOSIS  127 

Marriage  should  not  be  considered  in  the  case  of  a  person 
who  has  active  lung  tuberculosis  with  germs  in  the  expec- 
toration. Whether  marriage  is  proper  in  the  case  of  indi- 
viduals with  healed,  inactive,  or  closed  lesions  in  the  lungs 
depends  upon  all  the  circumstances  involved,  and  an 
expert  should  decide.  A  person  may  have  active  tuber- 
culosis, apparently  recover,  and  yet  be  a  carrier  of  tuber- 
culosis germs  in  his  expectoration,  as  in  the  classical 
instance  of  the  recovered  consumptive  who  caused  the 
death  of  four  wives  by  tuberculosis  while  remaining  in 
apparent  health  himself. 

A  patient  with  active  tuberculosis  who  is  able  to  be 
about  and  care  for  himself  may  not  be  a  source  of  any 
danger  to  others  by  conscientiously  adopting  the  follow- 
ing precautions:  His  expectoration  should  always  be 
deposited  in  a  pasteboard  box,  made  for  the  purpose, 
which  is  daily  burned  with  its  contents.  The  use  of  hand- 
kerchiefs or  cloths  leads  to  soiling  of  the  hands,  pockets, 
bed  clothes,  etc.  When  coughing  in  the  presence  of 
others  a  paper  handkerchief  should  be  held  before  the  face 
to  prevent  spraying  of  the  germs  into  the  air  of  the  room. 
Any  object  placed  in  the  mouth  should  be  burned,  as 
toothpicks,  cigar  butts,  etc. 

The  tooth-brush  should  be  used  three  times  daily,  over 
the  toilet  and  not  over  a  wash  basin.  The  face  should  be 
kept  shaven  and  the  face  and  hands  washed  frequently. 
It  has  been  found  that  the  ordinary  washing  of  eating 
utensils  is  sufficient  to  prevent  contagion  from  them,  but 
the  napkin  should  be  kept  in  a  separate  envelope  unless 
used  but  once. 

The  bed  and  body  clothing  should  be  boiled  for  ten 
minutes  before  being  sent  to  the  laundry.  The  patient's 
room  should  be  cleaned  without  stirring  up  dust,  using  a 
moist  cloth  or  wet  broom,  or,  better,  vacuum  cleaning. 


128  THE    PREVENTION    OF   DISEASE 

The  bed  should  be  covered  with  a  counterpane  which  is 
frequently  washed,  and  the  upper  sheet  should  be  turned 
down  well  over  the  blankets  to  protect  them  from  the 
patient's  coughing  and  sneezing. 

With  such  precautions  patients  make  safe  companions, 
as  shown  by  the  fact  that  there  is  no  danger  from  patients 
to  attendants  in  well-regulated  sanatoriums. 

New  York,  under  the  supervision  of  Dr.  Herman  Biggs, 
is  the  model  city  of  the  world  in  the  public  control  of  tuber- 
culosis. The  death-rate  from  tuberculosis  has  been  reduced 
50  per  eent.  in  the  last  twenty-five  years,  or  from  3.98  to 
1.97  per  thousand.  This  is  accomplished  by  compulsory 
notification  of  cases,  printed  instructions  sent  to  patients, 
special  hospitals,  free  dispensaries,  and  visiting  nurses  for 
charity  cases;  free  examination  of  expectoration  and  early 
diagnosis,  free  dispensing  of  sputum  cups,  medicines  and 
food,  and  disinfection  of  all  premises  occupied  by  con- 
sumptives. By  far  the  most  important  of  all  measures  to 
prevent  the  spread  of  tuberculosis  is  the  segregation  of 
advanced  cases  in  hospitals,  and  this  has  been  the  chief 
means  all  over  the  world  of  lessening  the  number  of  patients 
and,  therefore,  the  mortality. 

As  we  have  seen,  chronically  enlarged  glands  in  the  neck 
in  children  are  very  common  and  usually  are  tuberculous, 
and  in  course  of  time  the  germs  find  their  way  into  the 
blood  and  may  in  the  end  lead  to  disease  of  the  lungs. 
Therefore  it  is  extremely  important  to  cure  enlarged  glands. 
Removal  of  diseased  tonsils  and  adenoids  in  children, 
x-ray  treatment  of  the  glands,  combined  with  a  diet  of 
milk  and  eggs,  and  living  and  sleeping  outdoors,  will 
usually  cure  the  glandular  swellings  in  the  neck.  In 
adults  removal  by  the  knife  is  commonly  advisable. 

To  prevent  tuberculosis  in  children  cows'  milk  should 
be  pasteurized.  The  cleanest  milk  is  best,  certified  if 


TUBERCULOSIS  129 

possible.  Home  pasteurization  is  safest  unless  one  is  sure 
of  the  dealer.  Fill  the  outer  part  of  a  2-quart  double 
boiler  as  high  as  possible  with  water  and  bring  it  to  the 
boiling-point.  Then  take  off  the  fire  and  place  a  quart  of 
milk  in  the  inner  part  of  the  boiler  and  insert  this  in  outer 
part.  Put  on  the  cover  and  let  the  double  boiler  stand 
with  a  cloth  over  it  in  a  warm  place  for  forty-five  minutes. 
Then  cool  the  milk  and  keep  the  milk  covered  on  ice.  The 
milk  should  be  kept  at  145°  F.  for  thirty  minutes,  and  to 
secure  this  it  is  well  to  test  it  with  a  thermometer  during 
the  heating  process. 

Cleaning  and  disinfecting  rooms  occupied  by  con- 
sumptives are  of  great  importance.  Mattresses  and  car- 
pets which  cannot  be  sterilized  by  a  municipal  steam  plant 
should  be  burned. 

Disinfection  by  formalin  is  most  effective,  followed  by 
general  cleaning  and  renovation.  For  this  the  furniture 
should  be  moved  from  the  walls,  rugs  lifted  from  the  floor, 
and  clothing  exposed. 

Then  2  cups  (^  pint)  of  formalin  are  mixed  with  a  cup 
of  water  in  a  water  pitcher,  and  to  this  is  slowly  added 
3  fluidounces  of  commercial  sulphuric  acid. 

One  pound  of  quicklime  is  placed  in  a  large  enamel  basin 
on  some  bricks  in  the  center  of  the  room  and  the  solution 
in  the  pitcher  is  poured  over  the  lime  and  the  door  quickly 
closed  and  sealed  by  strips  of  paper  pasted  over  the  cracks. 
This  quantity  of  chemicals  is  sufficient  for  an  ordinary  small 
bedroom  (10  x  10  x  10  feet — 1000  cu.  ft.)  which  is  reason- 
ably tight.  After  the  room  has  been  closed  for  twelve 
hours  it  should  be  aired  and  everything  possible  washed 
with  soap  and  water  containing  a  generous  tablespoonful 
of  compound  cresol  solution  to  the  quart.  Then  the  walls 
and  ceiling  may  be  calcimined  or  prepared  so  as  to  secure 
the  most  complete  renovation.  All  fabrics  and  bed  or  body 

9 


130  THE    PREVENTION   OF   DISEASE 

clothing  should  be  boiled  for  twenty  minutes,  or  soaked  in 
1  : 1000  corrosive  sublimate  solution  over  night. 

The  prevention  of  overcrowding  in  factories  and  work- 
shops, and  medical  examination  at  regular  intervals  of 
employees  in  stores  and  in  buildings  in  which  large  numbers 
of  persons  are  working,  are  of  great  value  in  limiting  the 
ravages  of  tuberculosis. 

The  chief  measures  of  prevention  are  three:  1.  Segrega- 
tion of  advanced  cases  to  avert  distribution  of  enormous 
numbers  of  germs.  2.  Early  diagnosis.  3.  Improvement 
of  individual  health. 

COLD  IN  THE  HEAD 

Colds  are  due,  in  the  first  instance,  to  changes  in  the 
circulation,  and,  secondly,  to  the  presence  of  certain  germs 
in  the  nose  and  throat. 

Thus,  in  the  classic  experiments  of  Rossbach,  who  opened 
the  windpipes  of  rabbits  and  placed  ice  on  their  bellies,  it 
was  found  that  the  cold  on  the  outside  of  the  body  pro- 
duced intense  congestion  in  the  air-passages.  It  is  well 
known  that  exposure  to  cold  or  wet  (the  same  thing)  is 
likely  to  cause  a  "cold,"  especially  if  one  is  overheated  at 
the  time.  Other  conditions  leading  to  abnormal  conges- 
tion of  the  mucous  membranes  likewise  favor  colds,  as 
chronic  catarrh  from  any  cause — commonly  nasal  obstruc- 
tions, diseased  tonsils,  and  adenoid  growths,  particularly 
in  children.  Irritation  of  the  mucous  membranes  of  the 
nose  and  throat  is  also  occasioned  by  hot,  dry  air,  as  from 
the  effect  of  hot-air  furnaces  and  by  dust,  and,  apparently, 
by  some  forms  of  indigestion  and  debility.  If  the  resist- 
ance of  the  mucous  membranes  to  germs  is  not  lowered  by 
the  foregoing  means  then  the  presence  of  germs  which  are 
ordinarily  found  in  the  air-passages  may  do  no  harm.  Or, 
again,  the  transmission  of  actively  infectious  germs  from  a 


COLD    IN    THE    HEAD  131 

patient  may  lead  to  an  attack  of  cold  in  healthy  persons. 
A  variety  of  germs  are  commonly  found  in  the  nasal  dis- 
charges of  those  with  colds,  one  or  the  other  preponder- 
ating, according  to  season  and  place.  These  may  be  germs 
causing  true  influenza,  or  those  producing  pneumonia 
(when  they  may  attack  the  lung,  which  they  ordinarily 
do  not  in  colds),  or  those  responsible  for  inflammation  of 
wounds  (pus  germs) ,  or  a  special  germ  (Micrococcus  catar- 
rhalis),  which  is  the  sole  source  of  some  colds. 

Thus,  two  factors  are  essential  for  the  production  of 
colds — congestion  of  the  mucous  membranes  and  the 
presence  of  certain  germs — and  apparently  both  are  neces- 
sary. In  places  free  from  germs,  as  on  mountain  tops  and 
in  arctic  regions,  exposure  to  cold  and  wet  does  not  ordi- 
narily induce  colds  on  account  of  the  absence  of  germs; 
while,  on  the  other  hand,  our  nasal  passages  may  contain 
the  same  germs  found  in  the  discharges  of  those  with 
severe  colds,  and  yet  we  may  remain  absolutely  well  if  we 
keep  our  mucous  membranes  in  good  condition. 

To  avoid  colds  we  must,  then,  avoid  chronic  catarrh,  dry 
overheated  air,  city  dust,  indigestion,  dissipation,  or  any 
causes  lowering  the  general  tone  or  the  local  tone  of  the 
mucous  membranes.  In  children  removal  of  enlarged 
tonsils  and  adenoids  are  often  required,  and  removal  of 
nasal  obstructions  in  adults.  Vaccines  made  of  all  the 
varieties  of  (killed)  germs  which  are  found  in  the  nasal  dis- 
charges of  persons  with  colds  are  now  used  to  induce  im- 
munity in  those  subject  to  repeated  attacks  and  also  in 
treatment  of  an  existing  cold.  Their  use  is  harmless,  but 
how  much  value  may  be  attributed  to  them  it  is  yet  too 
early  to  affirm.  It  is  difficult  to  understand  why  vaccines 
should  afford  immunity  to  colds  when  the  having  of  a  cold 
affords  no  protection  to  the  patient  against  taking  another. 
They  are  beginning  to  be  used  extensively,  however. 


132  THE    PREVENTION    OF   DISEASE 

What  shall  be  done  on  the  first  premonition  of  a  cold— 
when  one  feels  a  stuffiness  in  the  nose,  sneezes  frequently, 
has  a  roughness  or  dryness  and  discomfort  in  the  upper  part 
of  the  throat,  and  chilliness. 

Both  general  and  local  measures  are  advisable.  General 
treatment  consists  in  increasing  the  normal  secretions  of 
the  skin,  bowels,  and  kidneys.  Thus,  one  should  take  a 
laxative — one-half  to  one  bottle  of  effervescing  citrate  of 
magnesia — should  drink  a  quart  or  so  of  hot  lemonade,  and 
take  a  hot  bath  before  retiring,  or  a  Turkish  bath  may  be 
taken  if  one  can  drive  directly  home  without  exposure  and 
go  to  bed  at  once.  Capsules,  each  containing  1  grain  of 
quinin,  \  grain  of  camphor,  and  -fa  grain  of  extract  of 
belladonna,  are  useful  in  the  very  beginning  of  a  cold. 

One  should  be  taken  each  hour  until  four  or  five  have 
been  swallowed,  unless  there  is  much  dryness  of  the 
mouth,  when  it  is  well  to  stop  them. 

If  the  nose  is  much  obstructed  it  is  well  to  take  a  few  of 
these  tablets  at  any  time  to  lessen  the  swelling  in  the  nose, 
by  causing  contraction  of  the  blood-vessels  of  the  mucous 
membrane.  Taking  a  2-grain  capsule  of  quinin  hourly, 
until  three,  four,  or  five  doses  are  swallowed,  or  until  there 
is  ringing  in  the  ears,  appears  to  have  some  influence  in 
preventing  colds,  but  is  less  effective  than  the  above  com- 
bination. 

Among  the  local  remedies  the  dropping  of  half  a  medicine- 
dropperful  of  a  freshly  made  20  per  cent,  watery  solution  of 
argyrol  in  each  nostril  the  writer  has  found  most  useful  in 
aborting  a  cold  if  used  a  few  times  at  three-hour  intervals 
at  the  first  suggestion  of  the  trouble.  The  head  should  be 
thrown  well  back,  and  a  medicine-dropper  is  filled  half-full 
of  the  solution,  which  is  allowed  to  flow  slowly  into  the 
nose  and  so  on  into  the  throat. 

The  solution  is  harmless  if  swallowed.     It  is  well  not  to 


COLD    IN    THE    HEAD  133 

blow  the  nose  afterward  more  than  possible,  and  to  use 
pieces  of  cheese-cloth  or  old  bits  of  cotton,  which  may  be 
thrown  away  as  soon  as  used,  for  the  solution  will  stain  the 
handkerchief  badly.  These  stains  may  be  immediately 
removed,  however,  by  a  1  : 1000  solution  of  corrosive  sub- 
limate made  with  the  ordinary  surgical  tablet.  Argyrol 
is  a  most  useful  agent  in  preventing  the  growth  of  germs 
when  locally  applied,  and  will  prevent  the  occurrence  of 
the  most  dangerous  inflammations  of  the  eye  and  of  the 
sexual  organs  (see  page  191).  When  there  is  much  obstruc- 
tion in  the  nose  and  breathing  through  it  becomes  difficult 
one  may  sniff  up  occasionally  into  the  nostrils  a  little 
Pond's  extract  or  witchhazel  from  the  hand,  which  will  be 
found  very  effective.  But  this  is  not  a  dissertation  on  the 
treatment  of  cold,  and  we  must  stick  to  our  subject  of 
prevention.  The  argyrol  solution  may  be  dropped  into  the 
nostrils  of  infants  or  children  while  they  are  lying  in  bed 
without  causing  distress  or  subjecting  the  patient  to  the 
slightest  danger  from  swallowing  the  medicine.  As  the 
solution  does  not  keep  well  for  longer  than  a  week,  one  may 
use  in  its  place  a  solution  of  1\  grains  each  of  menthol  and 
camphor  in  an  ounce  of  liquid  albolene  (similar  to  liquid 
vaselin),  dropped  into  each  nostril  in  the  same  manner, 
and  this  solution  is  useful  throughout  a  cold  when  dropped 
in  the  nose  four  times  daily,  and  for  children  is  preferable, 
in  that  it  will  not  stain  the  clothing  as  does  the  argyrol. 
This  is  also  absolutely  harmless  if  swallowed. 

The  best  treatment  of  all  severe  colds  is  that  secured  by 
remaining  in  bed.  While  the  temperature  is  over  99|°  F. 
one  is  always  safer  in  bed  with  a  cold.  The  even  warmth 
of  the  coverings  tends  to  bring  the  blood  to  the  surface  of 
the  body  and  relieve  the  congestion  in  the  air-passages. 
It  is  the  direct  opposite  of  Rossbach's  cold  applied  to  the 
outside  of  the  abdomen  in  producing  congestion  in  the 


134  THE   PREVENTION   OF   DISEASE 

breathing  apparatus.  For  persons  subject  to  colds  the 
daily  sniffing  of  a  solution  made  from  Seller's  alkaline 
antiseptic  tablets  (one  tablet  to  half  a  cup  of  warm  water) 
into  the  nostrils,  and  the  gargling  of  the  throat  with  a  half 
pint  of  cold  water  twice  daily,  are  of  great  benefit  in  cleans- 
ing these  parts  of  germs.  Then,  as  is  well  known,  the 
hardening  of  the  skin  by  daily  cold  baths,  showers,  or  cold 
sponging  (in  delicate  persons  while  standing  in  warm 
water)  will  be  of  great  service.  Persons  with  bald  heads 
may  bathe  their  heads  in  cold  water. 

Cold  baths  should  not  be  taken  unless  a  warm  reaction 
follows,  and  the  use  of  a  very  warm  bathroom  greatly 
favors  this  result.  Also  light  underclothing  is  of  advantage 
in  hardening  the  skin,  and  many  persons  catch  cold  by  the 
opposite  process  through  wearing  too  warm  underclothing 
in  cold  weather.  The  material  is  not  of  so  much  im- 
portance; light  wool  is  best,  but  many  do  as  well  with 
cotton  or  linen.  So  children  should  be  brought  up  to 
scorn  drafts,  unless  the  skin  is  moist  from  perspiration. 
It  does  one  good  to  get  used  to  sitting  in  drafts  and  thus 
harden  the  skin  to  cold,  with  the  above  exception.  Germ- 
laden  dust  is  one  of  the  most  prolific  sources  of  colds  and 
pneumonia  in  cities.  Clean  pavements  will  prevent  this 
danger.  In  Seattle  the  streets  are  paved  with  brick  or 
asphalt,  and  are  washed  daily  with  a  hose  in  the  business 
sections,  and  this  city  has  the  lowest  death-rate  in  the 
United  States.  Infants  should  not  be  taken  out  in  cities 
when  the  air  is  filled  with  dust  unless  the  face  is  well  pro- 
tected by  a  veil.  The  general  precautions  which  are  ad- 
vised herein  will  apply  as  preventive  measures  against  dis- 
eases of  the  air-passages  and  lungs  as  a  whole,  including 
bronchitis  and  pneumonia. 

There  is  one  favorite  preventive  against  cold,  recom- 
mended by  the  justly  famous  Dr.  Alonzo  Clark,  which  we 


INFLUENZA,    LA    GRIPPE  135 

have  omitted.  It  consisted  in  hanging  one's  hat  on  the 
bedpost  and  drinking  whisky  and  water  until  one  sees 
two  hats.  Times  have  changed,  and  neither  present  mor- 
als nor  scientific  teaching  favor  this,  to  some,  agreeable 

treatment. 

INFLUENZA,  LA  GRIPPE 

It  is  difficult  to  define  what  influenza  is.  Many  doctors 
call  any  severe  cold  with  fever  influenza.  Since  Pfeiffer's 
discovery  (in  1893)  of  a  special  germ  as  the  sole  cause  of 
influenza,  one  would  naturally  limit  the  cases  of  influenza 
to  those  in  which  the  Pfeiffer  germ  is  present.  But  the 
influenza  germ  is  found  in  the  nose  and  throat  secretions 
in  many  persons  who  are  suffering  from  other  diseases,  as 
bronchitis  and  consumption,  or  chronic  cough,  while, 
on  the  other  hand,  there  are  many  other  germs  which  pro- 
duce exactly  the  same  symptoms  as  those  caused  by  the 
true  influenza  bacillus.  Thus,  severe  influenza-like  colds 
are  due  commonly  to  the  same  germs  which  produce  blood- 
poisoning  in  wounds  (pus  germs) ,  or  to  those  which  under 
other  conditions  will  occasion  pneumonia,  or  to  a  third  kind 
of  germ  peculiar  to  severe  colds.  In  the  wide-spread  epi- 
demics of  influenza  which  after  an  interval  of  often  many 
years  extend  over  the  civilized  world  the  sole  cause  appears 
to  be  the  true  Pfeiffer  bacillus,  or  influenza  germ.  During 
the  periods  of  freedom  from  these  great  outbreaks  attacks 
precisely  resembling  influenza  may  be  either  due  to  the 
influenza  germ  or  to  the  others  already  noted.  It  is  well 
to  regard  all  severe  catarrhal  colds  with  fever  as  influenza 
because  they  also  are  contagious  and  should  be  treated  as 
influenza. 

Influenza  is  a  very  contagious  disease,  and  is  communi- 
cated by  contact  of  one  person  (carrying  the  influenza  germ 
in  his  nose  or  throat  secretions)  with  another  susceptible 
individual.  It  was  formerly  thought  that  the  disease  was 


136  THE    PREVENTION    OF   DISEASE 

communicated  through  the  air,  because  influenza  might 
suddenly  appear  in  persons  in  a  remote  island  or  other 
place  away  from  the  general  source  of  infection.  But  now 
that  we  know  that  persons  carry  about  influenza  germs 
in  the  secretions  of  their  nose,  throat,  and  bronchial  tubes 
for  years  there  is  nothing  to  prevent  such  an  one  from 
communicating  the  disease  in  an  active  form  to  any  sus- 
ceptible individuals  at  any  time. 

Yet  it  is  only  when  influenza  is  prevalent  that  one  can  in 
some  measure  use  preventive  means  to  avoid  the  disease. 
These  consist  in  attending  to  the  general  health,  refraining 
from  fatigue  and  undue  exposure,  and  keeping  from 
crowded  rooms  or  cars  or  buildings.  It  is  thought  by  some 
that  taking  1\  grains  of  quinin  in  capsules  three  times 
daily  at  mealtimes  or,  in  case  this  does  not  agree,  1\  grains 
of  urotropin  in  a  whole  glass  of  water  thrice  daily  between 
meals,  will  protect  an  adult  against  the  disease.  To  pro- 
tect healthy  persons  in  the  same  house  with  the  sick  it  is 
necessary  to  isolate  influenza  patients  in  a  room  and  burn 
all  the  secretions  from  the  nose  or  throat  which  may  be 
received  on  paper  handkerchiefs,  pieces  of  gauze,  or  cloth. 

Then  the  patient's  bed  and  body  clothing  should  be 
boiled  before  being  laundered,  and  the  drinking  and  eating 
utensils  should  also  be  placed  in  boiling  water  after  use. 
An  attack  does  not  protect  one  from  another;  in  fact, 
unlike  most  contagious  diseases,  instead  of  the  patient 
being  made  more  or  less  immune,  he  appears  to  be  made 
more  susceptible  to  the  disease. 

The  feeble,  aged,  and  children  should  be  protected  from 
influenza,  as  far  as  possible,  by  isolation  in  their  rooms  or, 
better,  outdoors  away  from  the  crowd.  So  many  persons 
go  alx)ut  with  influenza  that  it  is  not  possible  to  avoid 
them  in  crowded  places  during  epidemics.  Among 
thousands  of  fishermen  at  sea  none  contracted  influenza 


CEREBROSPINAL    MENINGITIS  137 

except  immediately  after  leaving  port  or  after  mixing  with 
the  crews  of  other  vessels.  The  time  of  development, 
from  exposure  to  the  appearance  of  the  first  symptoms,  is 
usually  only  two  to  three  days.  As  Dr.  Lord,  of  Boston, 
has  found  the  true  influenza  germs  in  25  to  59  per  cent,  of 
all  persons  with  cough  and  expectoration  (at  other  times 
than  during  influenza  outbreaks),  the  frequency  with 
which  exposure  is  possible  becomes  alarming.  The  moral 
is  to  treat  all  coughs  and  colds  as  contagious,  and  destroy 
the  secretions  by  burning  or  boiling  the  material  on  which 
they  are  collected,  while  the  patient  should  absent  himself 
as  much  as  possible  from  society.  Nothing  is  more  exas- 
perating than  to  have  a  friendly  (?)  visitor  introduce  a  bad 
cold  into  a  home  and  leave  a  long  trail  of  sickness,  suffering, 
and  expense  behind  him. 

CEREBROSPINAL  MENINGITIS 

This  is  a  disease  due  to  a  special  germ  (meningococcus). 
It  frequently  occurs  in  epidemics  and  in  the  country  rather 
than  in  cities.  Children  are  more  often  attacked,  although 
adults,  particularly  those  living  in  squalor  or  crowded  to- 
gether as  in  military  camps,  are  quite  susceptible.  It  is  not 
a  very  contagious  disease,  there  being  seldom  more  than 
one  or  two  cases  in  a  house.  However,  it  is  such  a  dreadful 
malady  that  all  possible  precautions  should  be  observed. 
Meningitis  usually  comes  on  suddenly  with  headache,  pains 
in  the  back  and  limbs,  chills,  and  vomiting.  So  far  it 
resembles  "grippe,"  but  its  peculiar  characteristics  include 
stiffness  and  rigidity  of  the  muscles  of  the  neck  and  back, 
with  a  drawing  backward  of  the  head,  and  the  whole  body 
may  be  so  stiff  that  a  person  can  be  lifted  like  a  statue. 
There  are  also  tremblings  or  spasms  of  the  muscles  of  the 
arms  and  legs.  Delirium  and  stupor  occur,  the  eyes  are 
sensitive  to  light  and  often  squint,  the  pupils  are  large,  and 


138  THE    PREVENTION    OF   DISEASE 

a  rash  often  appears  on  the  body.  The  wonderful  work  of 
Simon  Flexner  in  producing  a  serum  by  injecting  into  the 
blood-vessels  of  the  horse,  first,  a  solution  of  dissolved,  dead 
germs  of  cerebrospinal  meningitis  and,  later,  the  living 
virulent  germs  has  revolutionized  the  treatment  of  the  dis- 
ease. After  receiving  increasing  doses  about  four  months 
the  horse  is  bled  and  the  clear  fluid  (serum),  resulting  from 
clotting  of  the  blood,  is  injected  into  the  space  surrounding 
the  spinal  cord  of  human  patients  at  the  earliest  possible 
moment. 

In  meningitis  the  normal  fluid  surrounding  the  spinal 
cord  is  increased  greatly  in  amount  and  becomes  cloudy 
from  "matter"  or  pus. 

This  fluid  should  be  withdrawn  from  the  spinal  canal  in 
the  beginning  of  suspected  meningitis,  in  order  to  abso- 
lutely verify  the  diagnosis,  by  finding  the  special  germs 
with  the  microscope;  and,  again,  the  removal  of  this 
fluid  relieves  the  pressure  on  the  spinal  cord  and  brain 
and  may  occasion  a  corresponding  improvement  in 
the  symptoms,  as  headache,  delirium,  stupor,  etc.  This 
result  is  accomplished  by  inserting  a  strong,  hollow  needle 
through  the  muscles  over  the  spine  in  the  lower  part  of  the 
back,  directly  into  the  space  surrounding  the  spinal  cord. 
After  the  fluid  flows  out  through  the  needle  the  curative 
serum  is  allowed  to  flow  into  the  needle  from  a  funnel 
connected  with  the  needle  by  a  rubber  tube.  The  amount 
of  spinal  fluid  removed  and  serum  injected  are  controlled 
by  the  fall  of  blood-pressure  caused  by  both  these  pro- 
cedures. Serum  is  also  injected  under  the  skin,  and  the 
serum  treatment  is  generally  repeated  daily  for  three  or 
four  doses. 

Cerebrospinal  meningitis  is  a  very  fatal  disease,  death 
occurring  in  70  to  90  per  cent,  of  cases  without  the  serum 
treatment.  To  secure  the  best  results  the  serum  must  be 


CEREBROSPINAL    MENINGITIS  139 

given  within  the  first  three  days  of  the  disease,  when  the 
average  death-rate  is  reduced  to  34  per  cent.,  and  the  dura- 
tion of  the  disease  shortened  from  many  weeks  to  one  or 
two.  One  authority  (Sophian)  has  reported  a  mortality 
of  only  15.5  per  cent,  in  161  cases  of  cerebrospinal  menin- 
gitis by  the  most  skilful  use  of  serum. 

Prevention. — The  special  germs  (meningococci)  are  not 
found  outside  the  human  body,  and  they  die  within  a  few 
hours  when  dry  or  exposed  to  sunlight.  The  germs  may 
be  found  in  90  per  cent,  of  patients  in  the  nose  and  throat. 
The  disease  is  spread  by  patients  and  healthy  persons 
exposed  to  patients  who  carry  the  germs  about  in  the  nose 
and  throat  without  suffering  any  inconvenience,  or,  at 
most,  only  from  cold  in  the  head.  It  has  been  found  that 
55  per  cent,  of  healthy  persons  exposed  to  the  disease  be- 
come carriers,  or  that  there  are  ten  carriers  for  every  case 
of  meningitis. 

Carriers  may  communicate  the  germs  to  persons,  who,  in 
turn,  may  either  become  carriers  or  take  the  disease. 
Meningitis  germs  may  live  but  a  few  days  in  the  nose  and 
throat  of  carriers,  or  they  may  mostly  disappear  and  later 
reappear  in  large  numbers,  or,  if  the  carrier  becomes 
depressed  in  vitality,  the  meningitis  germs  may  invade  his 
blood  and  induce  a  real  attack  of  the  disease;  or,  finally, 
the  meningitis  germs  may  persist  in  the  nose  and  throat  of 
carriers  for  months  or  years.  In  the  case  of  patients  the 
germs  are  not  only  present  in  the  secretions  of  the  nose  and 
throat,  but  in  the  urine,  and  in  discharges  from  the  eyes, 
ears,  or  skin  eruptions. 

Patients  should  always  be  isolated  in  a  well-ventilated 
and  lighted  room,  stripped  of  carpet  and  unnecessary  fur- 
nishings. The  other  members  of  the  household  who  have 
been  exposed  should  also  be  quarantined  in  the  house, 
away  from  the  patient,  for  a  week,  or  until  cultures  taken 


140  THE   PREVENTION   OF   DISEASE 

from  the  nose  and  throat  on  two  occasions  show  the  absence 
of  meningitis  germs.  The  cultures  are  taken  exactly  as  in 
the  case  of  diphtheria.  In  order  to  get  rid  of  the  meningitis 
germs  in  the  nose  and  throat  one  should  spray  these  parts 
with  a  solution  containing  5  grains  of  common  salt  to 
2  tablespoonfuls  of  water,  or  with  Seller's  or  Dobell's 
tablets  dissolved  in  water  according  to  directions,  three 
times  daily,  and  after  a  few  days  the  desired  result  will 
usually  be  accomplished.  Children  should  not  be  per- 
mitted to  use  any  but  personal  handkerchiefs,  pencils, 
eating  utensils,  food,  etc. 

The  discharges  of  patients  should  be  burned  and  the 
urine  disinfected,  as  advised  under  Typhoid  Fever.  All 
handkerchiefs,  bed  and  body  clothing,  and  eating  utensils 
used  by  patients  should  be  boiled  after  use.  It  is  not 
necessary  to  disinfect  rooms  after  occupation  by  the  sick, 
as  sunlight  and  ventilation  are  sufficient.  During  an 
epidemic  the  congregation  of  persons  in  public  should  not 
be  allowed  and  schools  may  be  closed.  Care  should  be 
taken  to  avoid  colds  or  to  have  them  carefully  treated, 
and  close  intimacy  in  talking,  sneezing,  coughing,  and  kiss- 
ing are  inadvisable.  Children  should  not  use  articles 
which  have  been  in  the  mouths  of  others,  as  cups,  pen- 
cils, handkerchiefs,  food,  gum,  etc.  One  should  avoid 
close  contact  with  persons  having  colds,  and  handker- 
chiefs which  have  been  used  by  them  should  be  boiled. 
Plenty  of  fresh  air  and  sunshine  soon  kill  the  germ 
in  the  house.  Nurses  should  wear  gowns  and  caps 
in  attending  the  sick,  and  cover  their  faces  with  gauze 
when  exposed  to  the  breath  of  patients.  Taking  10 
grains  of  urotropin  in  a  glass  of  water  three  times  daily 
will  protect  healthy  persons  against  the  disease  to  a 
certain  extent  by  acting  as  an  antiseptic  on  the  various 
secretions  and  excretions  of  the  body.  There  are  two 


INFANTILE    PARALYSIS    (POLIOMYELITIS)  141 

special  preventives  which  are  more  effective  than  all 
others.  Vaccines,  as  in  typhoid  fever,  composed  of  the 
dead  bodies  of  meningitis  germs  in  solution  are  injected 
under  the  skin  at  intervals  of  a  week  or  ten  days  in  three 
doses.  The  first  dose  is  one-fifth  (100,000,000  germs)  that 
used  for  typhoid  fever.  This  treatment  is  as  yet  in  its 
infancy,  but  in  5000  persons  thus  protected  in  the  1913 
Texas  epidemic  there  were  no  cases  of  disease  and  the  treat- 
ment is  without  danger.  In  severe  epidemics  the  injec- 
tion of  the  serum  described  above  will  protect  the  indi- 
vidual for  two  or  three  weeks  when  given  in  small  doses 
(about  one  teaspoonful)  under  the  skin.  Vaccination 
requires  some  weeks  to  secure  protection,  but  it  is  then  of 
considerable  duration — probably  lasting  several  years. 
Serum  protects  at  once,  but  temporarily,  and  is  not  so 
desirable  if  the  patient  has  to  be  given  serum  later,  on 
account  of  the  possibility  of  producing  the  serum  disease 
discussed  under  Diphtheria. 

INFANTILE  PARALYSIS  (POLIOMYELITIS) 

This  disease  resembles  cerebrospinal  meningitis  in  many 
respects.  It  occurs  in  epidemics,  more  often  after  very 
hot  weather  in  the  latter  part  of  summer  or  autumn, 
and  frequently  is  seen  in  isolated  cases,  as  is  meningitis. 
Then,  again,  the  special  germ  of  the  disease  is  found  in 
the  brain  and  cord  and  in  the  secretions  of  the  nose  and 
throat,  as  in  meningitis.  Another  resemblance  lies  in 
the  fact  that  infantile  paralysis  is  contracted  through 
contact  with  the  sick  or  with  carriers,  i.  e.,  healthy  per- 
sons who  acquire  the  germ  through  exposure  to  the  sick 
or  from  other  carriers,  and  who  may  remain  carriers, 
or  communicate  the  disease  to  others,  or  take  the 
disease  themselves.  Even  when  the  germs  are  injected 


142  THE   PREVENTION    OF   DISEASE 

experimentally  into  the  brain  of  a  monkey  they  soon  ap- 
pear in  the  secretions  of  the  nose  and  throat. 

Another  similarity  of  infantile  paralysis  to  cerebrospinal 
meningitis  consists  in  the  circumstance  that  it  is  not  par- 
ticularly contagious,  and  in  this  respect  the  two  diseases 
may  be  classed  with  pneumonia. 

The  germ  of  infantile  paralysis  is  so  small  as  to  be 
invisible  microscopically,  except  in  mass.  It  grows  in  the 
nose,  throat,  and  nervous  system,  and  is  expelled  in  the 
bowel  discharges.  It  enters  the  brain  cavity  through 
openings  in  the-  skull  from  the  upper  part  of  the  nose. 
The  germs  then  attack  the  blood-vessels  of  the  nervous 
system.  The  blood-vessels  are  obstructed  and  the  blood- 
supply  to  the  nerve-cells  is  shut  off.  The  spinal  cord  and 
connecting  nerves  degenerate  and  paralysis  of  muscles 
ensues.  Susceptible  persons,  mostly  infants,  take  the 
disease  through  entrance  of  the  germs  into  their  noses 
and  throats.  These  germs  exist  in  the  discharges  from  the 
nose,  throat,  and  bowels  of  patients,  convalescents,  at- 
tendants, or  healthy  carriers.  They  are  conveyed  to  the 
healthy  by  means  of  soiled  fingers,  soiled  household  uten- 
sils, soiled  towels  and  handkerchiefs,  contaminated  food, 
and  flies.  One  may  inhale  the  germs  in  air  by  standing 
near  a  person  who  is  coughing  or  sneezing — if  he  has  them 
in  his  throat. 

After  entrance  of  the  germs  into  the  body  the  disease 
develops  within  two  to  fourteen  days — usually  eight.  The 
germs  may  be  carried  as  long  as  six  months  in  the  throat 
by  convalescents  or  healthy  exposed  persons.  The  latter 
may  not  take  the  disease  at  all. 

There  are  many  different  forms  of  the  disease,  and  no 
attempt  at  diagnosis  will  be  made  here,  since  even  the 
elect  are  often  puzzled. 

In  the  more  usual  case  the  patient  feels  dull  and  disin- 


INFANTILE    PARALYSIS    (POLIOMYELITIS)  143 

clined  to  play  or  work  and  fever  soon  appears.  The  whole 
body  is  sore  and  painful,  and  children  cry  on  being  moved. 
There  may  be  convulsions  in  children,  with  squinting  of 
the  eyes,  retraction  of  the  head,  and  stiffness  of  the  back 
muscles,  headache,  and  vomiting.  After  one  to  three  days 
of  fever  the  characteristic  paralysis  appears.  This  may 
be  of  one  leg  and  one  arm,  or  both  legs  or  arms,  or  of  all  the 
extremities.  More  often  one  leg  is  paralyzed  and  there  is 
either  involuntary  passage  of  the  urine  and  bowel  dis- 
charges or  the  urine  may  have  to  be  drawn  with  a  catheter. 
The  fever  and  other  symptoms  pass  away,  but  the  paralysis 
remains  unchanged  for  two  or  three  weeks,  and  then  im- 
proves during  the  following  months,  but  usually  some 
groups  of  muscles  begin  to  waste  away  and  the  limb  may 
remain  permanently  much  smaller  than  its  fellow.  When 
only  certain  muscles  are  involved  they  wither  and  de- 
formity results.  Club-foot,  where  children  walk  on  the 
heel  with  the  toes  drawn  up,  or  on  the  toes  because  the 
heel  is  drawn  up,  is  a  common  result.  Such  deformities 
can  now-a-days  be  quite  successfully  remedied  in  many 
instances.  The  danger  to  life  is  not  great,  varying  from 
4  to  15  per  cent,  mortality  (20  per  cent,  in  1916  epidemic). 
About  one-fifth  of  the  cases  make  complete  recovery. 

Prevention. — Apparently  infantile  paralysis  is  only  com- 
municated by  contact  of  the  sick  and  carriers  (or  by  ob- 
jects they  have  soiled  with  their  discharges)  with  healthy 
persons. 

The  patient  must  be  isolated  for  six  weeks,  and  also  the 
other  members  of  the  family,  and  exposed  persons  should 
be  quarantined  (except  bread  winners)  for  a  period  of  two 
weeks,  while  children  should  not  return  to  school  for  two 
months.  It  is  not  possible  to  determine  who  are  carriers 
by  taking  some  of  the  secretion  from  the  nose  and  throat 
for  examination,  as  in  diphtheria  and  cerebrospinal  menin- 


144  THE   PREVENTION   OP   DISEASE 

gitis,  because  the  germ  is  too  small  to  be  seen  microscopic- 
ally. If  possible  healthy  children  should  be  isolated  away 
from  centers  of  infection  in  the  country  during  epidemics, 
and  should  be  prevented  from  associating  with  other  chil- 
dren. The  kissing  of  children  should  also  be  thwarted. 

The  discharges  from  the  nose  and  throat  of  patients 
should  be  collected  on  cloth  in  a  paper  bag  and  burned, 
and  the  bowel  discharges  and  urine  should  be  disinfected 
as  in  typhoid  fever.  Bed  and  body  linen  and  eating  uten- 
sils should  be  boiled  for  ten  minutes  or  more  after  use. 
The  hands  of  the  nurse  should  be  frequently  washed  in 
soap  and  water.  The  sick  room  must  be  screened  from 
flies  and  regularly  disinfected  after  recovery  of  the  patient. 
Persons  exposed  to  the  disease  should  spray  their  throats 
three  times  daily  with  hydrogen  peroxid  1  part  to  3  parts 
of  water;  or  a  snuff  consisting  of  salol  65  grains,  menthol 
1  grain,  and  boric  acid  5  drams  is  recommended  (Dr. 
Dunn)  for  use  instead  of  the  spray,  a  pinch  to  be  sniffed  up 
into  each  nostril  thrice  daily.  The  use  of  urotropin  (5 
to  15  grains  in  a  whole  glass  of  water  three  times  a  day) 
for  the  exposed  members  of  the  family  may  protect  them 
in  acting  as  an  antiseptic  in  the  excretions  and  secretions, 
as  in  cerebrospinal  meningitis.  Unfortunately,  there  is  no 
certain  special  means  for  either  preventing  or  curing  in- 
fantile paralysis  at  the  present  time. 

The  dangers  of  contagion  are  greatly  magnified  during 
epidemics  of  infantile  paralysis.  It  is  not  readily  com- 
municated and  is  said  to  be  but  one-fifteenth  as  contagious 
as  scarlet  fever. 


CHAPTER  VII 

COMMON  LOCAL  TROUBLES  AS  A  SOURCE  OF 
SERIOUS  GENERAL  DISEASES 

Importance  of  Infections  of  Nose,  Mouth,  and  Throat. — 
Life  is  usually  ended  by  infections  or  germ  diseases.  An 
infection  does  not  mean  simply  the  presence  of  germs  in  a 
part,  but  their  growth  in  the  tissues,  with  the  accompany- 
ing.  formation  of  poisons  producing  the  symptoms  of  in- 
flammation, which  is  usually  synonymous  with  infection. 
Smithies,  at  Rochester,  Minn.,  found  that  80  per  cent,  of 
dyspeptics  had  pus  germs  in  their  saliva.  But  these  may 
theoretically  exist  in  the  mouth  without  actually  producing 
infection  or  inflammation,  unless  injury  to  the  mouth  by 
food,  hot  drinks,  sharp  teeth,  low  vitality,  or  some  other 
exciting  cause  enables  them  to  "take  hold"  and  grow.  As 
a  matter  of  fact,  it  is  probable  that  in  most  of  these  cases 
the  germs  were  present  as  the  result  of  inflammation,  since 
but  20  per  cent,  of  persons  have  normal  mouths  (Mayo). 

More  and  more  may  the  so-called  constitutional  diseases 
(supposed  to  result  from  unknown  functional  disturbances 
of  the  whole  system)  be  attributed  to  the  action  of  germs, 
as  rheumatism,  Bright's  disease  of  the  kidneys,  anemias, 
and  even  diabetes.  Formerly,  the  origin  of  these  diseases 
being  wrapped  in  mystery,  they  were  accepted  alike  by  doc- 
tors and  patients  with  a  resigned  fatalism.  But  progress 
in  science  is  illuminating  these  dark  spots  in  medicine  and 
offering  means  of  prevention  and  cure.  During  the  past 
few  years  the  remarkable  researches  of  Rosenow,  and  the 

10  145 


146  .    THE    PREVENTION   OF   DISEASE 

teaching  of  such  leaders  in  medicine  and  surgery  as  Billings 
and  Charles  Mayo,  have  pointed  to  local  infections  of  the 
nose,  mouth,  and  throat  as  the  chief  sources  of  serious  acute 
and  chronic  disease  in  many  parts  of  the  body.  This 
knowledge  cannot  be  too  widely  or  forcibly  impressed  upon 
the  intelligent  layman,  because  of  its  tremendous  signifi- 
cance and  common  application. 

It  is  generally  appreciated  that  the  nose  and  mouth  are 
the  openings  in  the  body  through  which  the  germs  of  most 
infectious  diseases  enter.  Typhoid  fever,  pneumonia, 
tuberculosis,  diphtheria,  epidemic  meningitis,  dysentery, 
cholera,  measles,  scarlet  fever  are  a  few  examples  of  diseases 
which  gain  entrance  by  these  portals.  It  has  been  well 
known  that  the  mouths  of  healthy  persons  always  contain 
a  great  variety  of  germs  (fifteen,  besides  many  other  acci- 
dentally present).  But  only  recently  has  it  been  actually 
demonstrated  that  the  presence  of  germs  in  acute  or 
chronic  inflammatory  disorders  of  the  nose,  throat,  and 
mouth  are  capable  of  being  carried  by  the  blood  to  various 
parts  of  the  body,,  there  giving  rise  to  the  most  diverse 
diseases,  the  source  of  which  has  been  hitherto  an  enigma. 

The  more  common  local  inflammations  in  the  head, 
which  are  responsible  for  damage  to  the  system  at  large, 
are  tonsillitis,  Riggs'  disease  affecting  the  gums  and  roots 
of  the  teeth,  abscesses  about  the  roots  of  the  teeth  from 
decay,  etc.,  and  nasal  catarrh  extending  to  the  adjoining 
cavities  (sinuses)  in  the  bones  of  the  face  and  forehead. 
These  diseased  conditions  are  not  by  any  means  easy  to 
determine  in  all  cases,  and  the  services  of  the  physician, 
nose  and  throat  specialist,  dentist,  and  x-ray  specialist  may 
all  be  required  to  secure  a  proper  diagnosis.  For  instance, 
simply  looking  at  the  tonsils  is  not  sufficient.  The  bands 
forming  the  entrance  to  the  throat  must  be  pushed  aside  to 
expose  the  tonsils,  and  these  should  be  pressed  upon  to 


LOCAL    TROUBLES    AS    SOURCE    OF    SERIOUS    DISEASES      147 

squeeze  out  any  inflammatory  secretion.  It  may  usually 
be  taken  for  granted  that  persons  who  have  had  repeated 
attacks  of  acute  tonsillitis  or  quinsy  are  almost  sure  to  have 
chronically  diseased  tonsils.  Enlarged  tonsils  and  adenoid 
growths  are  usually  diseased  also  and  should  be  removed. 
Again,  regarding  abscesses  about  the  roots  of  teeth :  These 
may  be  caused  by  infection  from  decay,  irritation  of  im- 
properly placed  crowns  or  bridge  work,  by  poor  dentistry 
in  allowing  space  for  food  to  collect  between  the  teeth,  and, 
strange  to  say,  in  most  cases  there  are  not  sufficient  pain 
or  tenderness  in  the  diseased  tooth  to  enable  the  patient 
or  dentist  to  locate  the  exact  site  without  an  x-ray  picture. 
Ulrich,  of  the  University  of  Minnesota,  finds  abscess  about 
the  roots  of  teeth  in  80  to  88  per  cent,  of  adults  by  means 
of  the  x-ray.  They  occur  at  the  ends  of  the  roots  in  68  per 
cent,  of  teeth  in  which  the  nerve  has  been  killed. 

The  same  difficulty  may  apply  to  the  detection  of  Riggs' 
disease  and  disease  of  the  sinuses  in  the  head.  While 
tenderness  of  the  teeth  and  gums  and  escape  of  pus  along 
the  edge  of  the  gums  on  pressure  are  ordinary  signs  of 
Riggs'  disease,  yet  in  some  instances  the  most  expert 
knowledge  may  be  necessary  to  detect  the  condition. 

Inflammation  of  the  sinuses  usually  demands  examina- 
tion by  the  nose  and  throat  specialist  for  its  determina- 
tion. The  symptoms  of  these  diseases  are  considered 
under  their  titles  elsewhere  in  this  book. 

But  in  other  parts  of  the  body  away  from  the  head 
local  infections  may  also  lead  to  serious  remote  diseases. 
Thus,  chronic  inflammation  of  the  appendix  and  gall- 
bladder, of  the  urinary  and  female  sexual  organs,  may  be 
included  in  this  category.  The  germs  from  even  slight 
local  infections,  as,  for  instance,  from  wounds  of  the  fingers 
or  of  an  ingrowing  toe-nail,  have  been  recorded  as  producing 
the  most  serious  disorders  in  remote  vital  organs  by  trans- 


148  THE   PREVENTION    OF   DISEASE 

mission  through  the  blood.  How  frequently  germs  in- 
habiting the  bowels  may  produce  chronic  disease  of  remote 
parts,  as  of  the  joints,  blood-vessels,  heart,  kidneys,  and 
blood,  is  uncertain,  but  this  source  is  accepted  by  many 
authorities.  In  this  connection  it  may  not  be  amiss  to 
mention  a  common  experience  that  persons  having  a 
chronic  appendicitis  are  often  attacked  a  few  years  later 
with  inflammation  of  the  gall-bladder  and  gall-stones. 
Whether  the  germs  in  the  inflamed  appendix  reach  the 
gall-bladder  by  transmission  through  the  lymph-vessels, 
or  whether  both  troubles  originate  from  germs  set  free  in 
the  blood  from  local  inflammations  of  the  nose,  mouth, 
and  throat,  it  is  impossible  to  say.  In  epidemics  of  ton- 
sillitis the  simultaneous  occurrence  of  appendicitis  among 
patients  has  often  been  observed. 

What  kind  of  germs  are  commonly  found  in  the  nose, 
mouth,  throat,  and  elsewhere  which  produce  serious  disease 
in  remote  organs? 

They  are  the  ordinary  germs  causing  inflammation  in 
wounds  and  abscesses,  the  pus  germs — streptococci  and 
staphylococci  (practically  always  present  in  the  adult 
mouth).  The  germs  of  pneumonia,  or  pneumococci,  are 
also  common.  It  has  been  found  that  the  characteristics 
of  these  germs  may  be  considerably  changed  in  their  growth 
in  the  nose,  mouth,  and  throat,  so  that  they  acquire  an 
affinity  for  certain  organs  after  entering  the  blood.  In 
this  way  we  explain  why  certain  parts  of  the  body  are 
attacked  by  germs  free  in  the  blood  rather  than  others. 
The  germs  circulating  in  the  blood  finally  lodge  in  the 
smallest  branches  of  the  vessels  in  the  tissues  which  they 
attack. 

How  do  we  know  that  local  infections  in  the  nose,  mouth 
and  throat,  and  in  other  parts  will  produce  serious  disorder 
of  remote  organs?  In  the  first  place,  the  association  of 


LOCAL    TROUBLES    AS    SOURCE    OF   SERIOUS    DISEASES      149 

certain  other  diseases  with  inflammations  in  the  throat  has 
been  a  matter  of  common  knowledge;  as,  for  instance,  the 
combination  of  rheumatism  and  valvular  disease  of  the 
heart,  both  secondary  to  tonsillitis.  Then  the  germs  found 
in  various  organs  secondarily  diseased  are  the  same  as 
those  occurring  in  the  primary  focus  of  inflammation  in  the 
head.  Recently  diseases  never  before  attributed  to  or 
associated  with  throat  or  mouth  infections  have  been 
found  to  have  a  causative  relation  to  the  latter,  because 
the  germs  found  in  the  various  organs  secondarily  diseased 
are  identical  with  those  in  the  original  focus  of  inflamma- 
tion in  the  throat.  This  applies  to  Bright's  disease  of  the 
kidneys,  ulcer  of  the  stomach,  inflammation  of  the  gall- 
bladder, appendicitis,  etc.  Moreover,  when  germs  from 
infected  human  tonsils  are  injected  into  the  blood  of 
animals  the  same  organs  are  attacked  as  those  secondarily 
diseased  in  man  with  tonsillitis;  that  is,  the  heart,  joints, 
stomach  (ulcer),  gall-bladder,  and  appendix. 

And,  finally,  surgical  removal  of  the  local  infectious  foci 
in  the  nose,  throat  and  mouth,  or  elsewhere  is  often  fol- 
lowed by  improvement  or  recovery  from  remote  diseases 
which  have  been  found  experimentally  and  in  practice 
associated  with  such  nose,  throat,  and  mouth  infections. 
Thus,  the  cutting  out  of  diseased  tonsils  may  be  the  means 
of  curing  rheumatism  and  valvular  disease  of  the  heart. 

It  would  be  absurd  to  affirm  that  all  sufferers  from  local 
infections  in  the  head  are  doomed  to  acquire  serious  remote 
disease,  for  most  persons  have  more  or  less  chronic  infec- 
tions about  the  nasal  passages,  mouth,  and  throat.  But 
the  possibilities  of  such  troubles  should  be  recognized  by 
the  laity  in  order  that  proper  attention  be  given  to  treat- 
ment. If  left  to  persist,  any  depressing  circumstances,  as 
colds,  dissipation,  financial  or  social  disasters,  overwork, 
poor  food  and  surroundings,  may  so  weaken  the  resistance 


150  THE   PREVENTION   OF   DISEASE 

of  the  body  that  the  escaping  germs  in  the  blood  may  at- 
tack some  vital  organ. 

For  instance,  there  is  a  most  painful  and  serious  inflam- 
mation of  the  bones  frequently  mistaken  for  rheumatism 
(osteomyelitis).  It  begins  with  the  severity  and  sudden- 
ness of  appendicitis,  and  in  twenty-four  hours  may  destroy 
the  bone  of  the  leg  or  thigh,  so  that  amputation  or  death 
may  result.  This  condition  doctors  have  described  as 
"idiopathic,"  a  cloak  for  ignorance  as  to  its  origin.  Now 
we  know  that  it  is  due  to  infections  about  the  nose  and 
throat,  colds,  sore  throat,  or  tonsillitis,  and  occurs  perhaps 
a  week  or  two  after  recovery.  But  this  point  I  wish  to 
emphasize,  that  the  bone  trouble  is  precipitated  by  a  slight 
fall  or  injury  to  the  limb  in  many  cases.  An  injured  point 
always  weakens  resistance  to  infections  from  within  or 
without.  In  other  words,  the  germs  from  the  inflammation 
in  the  throat  have  entered  the  blood,  and  a  slight  local 
injury  may  be  the  means  of  their  selecting  the  bones  for 
the  site  of  their  growth.  First,  the  cold,  next  the  injury, 
and  then  a  disease  fatal  to  life  and  limb,  unless  treated  at 
once  and  understandingly. 

A  categoric  list  is  never  interesting,  but  it  will  be  of 
advantage  to  impress  the  layman  more  specifically  with  the 
results  of  the  apparently  unimportant  local  infections  un- 
der consideration.  By  direct  extension — that  is,  the  direct 
transmission  of  the  germs  from  the  infection  in  the  nose, 
mouth,  and  throat  through  the  natural  drainage  spaces  and 
canals  in  the  tissues  (lymphatics) — the  glands  of  the  neck 
(the  normal  catch-basins  in  this  system)  become  enlarged 
and  tender.  Swollen  glands  or  lumps  under  the  ear  or  jaw 
are  the  most  common  complication  of  mouth  or  throat  in- 
fection. But  we  are  chiefly  concerned  with  the  more 
remote  dispersion  of  the  germs  after  they  enter  the  blood 
and  are  carried  to  other  parts  of  the  body.  One  of  the 


151 

most  frequent  results  is  a  condition  in  which  acute,  inflam- 
mation of  the  joints,  or  acute  rheumatism,  is  associated  with 
valvular  disease  of  the  heart.  Indeed,  it  has  been  shown 
that  certain  strains  of  streptococci  from  tooth  abscess 
and  tonsil  inflammation,  after  their  escape  into  the  blood, 
have  a  special  predilection  for  these  tissues — the  joints 
and  heart  valves.  In  fact,  all  joint  inflammations  (except 
those  due  to  gout  or  direct  injury)  are  probably  of  germ  or 
infectious  origin,  although  usually  masquerading  under 
the  meaningless  name  of  rheumatism.  Many  cases  may  be 
ultimately  cured  by  first  removing  the  cause  in  the  mouth 
or  throat.  In  childhood  there  may  be  also  an  added  com- 
plication— chorea  or  St.  Vitus'  dance — to  the  rheumatism 
(?)  and  heart  disease.  More  often  one  of  these  diseases 
occurs  separately  with  tonsillar  infection.  The  writer  has 
had  recently  under  his  care  a  boy  suffering  from  mild 
chorea  and  valvular  disease  of  the  heart,  associated  with 
chronic  tonsillitis,  from  which  he  has  wholly  recovered 
since  removal  of  his  tonsils.  Germs  in  the  blood  from 
diseased  tonsils  attack  the  valves  of  the  heart  and  set  up 
inflammation  and  distortion  of  the  valves,  which  then  fail 
to  close  and  become  leaky,  as  would  an  ill-fitting  valve  of 
a  pump. 

The  lodgment  of  the  same  germs  in  the  finest  blood- 
vessels of  the  joints  and  nervous  system  from  the  infected 
mouth  or  throat  gives  rise  to  the  rheumatism  (?)  and  St. 
Vitus'  dance. 

It  has  only  lately  been  discovered  that  many  nervous 
disorders  originate  apparently  in  the  same  way  from  germs 
in  the  blood  derived  from  the  infected  nose,  mouth,  or 
throat,  such  as  neuritis,  and  possible  melancholia  and  dis- 
turbances of  sensation  in  the  limbs  (feeling  of  pricking  by 
needles  and  pins). 

It  has  recently  come  to  my  knowledge  that  a  patient  who 


152  THE   PREVENTION    OF   DISEASE 

has  been  the  medical  rounds  for  constant  pain  in  one  arm, 
from  neuritis,  has  been  wholly  cured  by  removal  of  diseased 
tonsils.  Goiter,  or  swelling  of  the  gland  that  lies  under  the 
"Adam's  apple"  in  the  neck,  is  another  disease  of  doubtful 
origin.  In  some  cases  at  least  this  trouble  appears  to  arise 
from  infection  with  germs  in  the  blood  derived  from  "dis- 
eased tonsils.  The  same  remark  applies  to  a  very  serious 
disorder  with  swelling  of  glands  in  various  parts  of  the 
body  (Hodgkin's  disease). 

The  cause  of  gall-bladder  inflammation,  gall-stones, 
appendicitis,  and  chronic  ulcer  of  the  stomach  and  first 
part  of  the  intestines  has  been  the  subject  of  much  specu- 
lation, experiment,  and  controversy,  but  these  disorders 
may  be  reproduced  in  animals  by  injection  into  their  blood 
of  streptococci  from  diseased  human  tonsils,  and,  moreover, 
these  same  germs  are  found  in  the  diseased  human  gall- 
bladder and  ulcerated  stomach  and  intestines.  Thus, 
apparently  we  have  a  positive  demonstration  of  at  least 
one  of  the  causes  of  these  diseases. 

Some  of  the  inflammations  in  the  nose,  throat,  and  mouth 
are  due  to  the  germs  of  pneumonia,  and  while  these  may 
be  constantly  present  and  may  not  produce  pneumonia, 
yet  it  is  to  the  escape  of  germs  into  the  blood  from  these 
sources  that  we  must  attribute  pneumonia  in  some  in- 
stances. 

A  certain  percentage  of  the  tonsils  (15  per  cent.)  removed 
are  found  to  be  infected  with  tuberculosis  germs.  Tuber- 
culosis of  vital  organs,  as  the  lungs  and  kidneys,  may  arise 
from  entrance  of  the  tubercle  germs  into  the  blood  from 
tuberculous  tonsils.  The  streptococci,  so  often  the  cause 
of  inflammations  in  the  mouth,  nose,  and  throat,  are  also 
the  source  of  erysipelas  and  rashes  which  resemble  scarlet 
fever. 

The  so-called  idiopathic  (cause  unknown)  cases  of  cry- 


LOCAL   TROUBLES    AS    SOURCE    OF    SERIOUS    DISEASES      153 

sipelas  may,  in  fact,  be  due  to  primary  inflammations  in 
the  nose,  throat,  or  mouth. 

When  diphtheria  antitoxin  (horse  blood-serum)  is  in- 
jected at  long  intervals  into  a  human  being  he  may  rarely 
develop  sudden  and  alarming  symptoms,  with  difficulty  of 
breathing  and  evidence  of  lack  of  air  or  oxygen.  This  fol- 
lows because  the  system  has  become  so  sensitized  to  this 
foreign  substance  that  a  later  dose  may  produce  the  most 
alarming  condition.  It  is  now  thought  that  the  system 
likewise  becomes  sensitized  to  the  poisons  constantly  pro- 
duced by  the  growth  of  germs  in  chronic  inflammations  in 
the  nose  and  throat,  and  the  result  is  difficulty  in  breath- 
ing and  asthma,  or  skin  eruptions  (nettle-rash),  such  as  are 
seen  in  poisoning  by  antitoxin.  Asthma  is  frequently 
cured  by  removal  of  diseases  in  the  nose  and  throat. 

Particular  emphasis  must  be  laid  on  the  fact  that  not 
only  the  head  infections,  but  any  local  focus  of  infection 
anywhere  in  the  body  constitutes  a  constant  menace  to  the 
host.  The  nose,  mouth,  and  throat  infections  have  been 
especially  dwelt  upon  because  they  are  so  common  and 
familiar.  There  are  fashions  in  medicine,  as  in  clothing, 
and  the  profession  continually  suffers  from  kangaroo-like 
mental  jumps  in  its  action  over  new  discoveries. 

Perhaps,  as  the  result  of  recent  researches  in  head  infec- 
tions, too  many  comparatively  healthy  tonsils  may  be 
removed  without  reason. 

When  they  are  unquestionably  infected  they  should  be 
cut  out,  and  all  means  should  be  exhausted  in  extirpating 
all  apparently  unimportant  infections  anywhere  in  the 
body  to  avoid  remote  serious  disease  of  vital  organs. 
There  is  an  ancient  proverb— "Study  sickness  when  you 
are  well."  This  is  even  truer  in  the  case  of  the  near- well. 

Tonsils  and  Adenoids. — While  the  cause  of  enlarged  and 
diseased  tonsils  and  adenoid  growths  is  not  absolutely 


154  THE   PREVENTION    OF   DISEASE 

determined,  it  is  probable  that  breathing  a  bacteria-laden 
air  may  produce  these  conditions  in  schools  or  whenever 
individuals  are  crowded  together  in  ill-ventilated  rooms. 

However,  enlarged  tonsils  and  adenoids  are  the  first  signs 
we  have,  and  these  are  commonly  called  to  our  attention 
owing  to  frequent  attacks  of  cold  or  tonsillitis  or  by  mouth- 
breathing.  Any  layman  can  tell  by  looking  into  the  back  of 
the  throat  whether  the  tonsils  are  enlarged  (Fig.  2,  A),  be- 


Fig.  2. — A,  Enlarged  and  diseased  tonsils.     The  normal  tonsils  are 
invisible.     (Redrawn  after  Matthews.) 


cause  in  health  they  are  not  visible  at  all  (as  projections  on 
either  side  of  the  entrance  to  the  throat) .  Adenoid  growths 
cannot  be  seen,  but  fill  the  region  at  the  back  of  the  nasal 
chambers  where  these  join  the  top  of  the  throat  (Fig.  3,  A). 
When  the  tonsils  are  enlarged  in  children  it  is  safe  to  infer 
that  adenoid  growths  also  occur.  The  only  efficient  treat- 
ment is  by  surgical  removal,  in  children  under  ether,  and  in 
adults  under  cocain  or  ether.  Only  within  a  few  years  has  it 


LOCAL    TROUBLES    AS    SOURCE    OF    SERIOUS    DISEASES      155 

been  customary  to  do  more  than  slice  off  the  outer  part  of 
the  tonsils,  but  it  has  been  found  that  the  tonsils  enlarge 
again  after  this  operation,  and  that  the  scar  covering  the  re- 
maining stump  of  the  tonsil  seals  it  over  and  retains  germs 
and  poisons  in  the  tonsil  which  are  then  all  the  more  likely 
to  be  absorbed  and  to  poison  the  system.  The  only  proper 
procedure  is  complete  removal  of  the  tonsil,  which  is  a  much 
more  difficult  operation  and  requires  the  services  of  an 


Fig.  3. — E  shows  about  the  level  of  the  eustachian  tube  con- 
necting the  throat  with  the  ear.  The  adenoid  growth  (A)  blocks 
up,  or  causes  mucus  and  swelling  to  block,  the  eustachian  tube 
and  induces  deafness  among  other  troubles  (Zuckerkandl). 

expert  throat  specialist  in  most  instances.  As  adenoid 
growths  interfere  with  breathing,  and  therefore  the  general 
health,  produce  deafness  by  stopping  the  tubes  which  lead 
from  the  upper  part  of  the  throat  to  the  inner  region  of  the 
ears,  and  favor  abscess  of  the  inner  ear  with  its  frequent 
extension  to  the  bone  of  the  skull  back  of  the  ear  (mastoid 
process),  and  then  to  the  brain,  it  will  be  seen  that  there  are 
more  than  sufficient  reasons  for  the  removal  of  diseased 


156  THE    PREVENTION    OF   DISEASE 

tonsils  and  adenoids — when  such  is  without  danger  and 
without  any  bad  consequences. 

Nor  is  the  train  of  consequences  caused  by  the  presence 
of  adenoids  by  any  means  exhausted.  The  obstruction 
to  breathing  leads  to  many  other  troubles.  Thus  the  face 
becomes  dull  and  stupid  and  the  mouth  is  held  open,  im- 
parting a  vacant  expression  to  the  face.  The  upper  jaw  is 
narrowed,  the  roof  of  the  mouth  becomes  high,  the  lips  are 


Fig.  4. — Expression  in  adenoids  (Friihwald). 

thick,  and  the  entrance  to  the  nostrils  is  slit-like  and  has  a 
"pinched-in"  appearance.  The  breathing  is  apt  to  be 
noisy  and  snorting  at  night  and  screaming  and  shortness  of 
breath  during  sleep  are  common.  Alterations  in  the  shape 
of  the  chest  follow,  as  the  narrow,  pointed  chest,  or  what  is 
called  chicken-  or  pigeon-breast ;  or,  if  there  is  asthma,  the 
chest  becomes  rounded;  and  occasionally  a  depression 
forms  at  the  lower  end  of  the  breast  bone.  The  nasal 


LOCAL    TROUBLES    AS    SOURCE    OF    SERIOUS    DISEASES      157 

voice  is  an  ordinary  accompaniment.  Headache,  fre- 
quent colds,  loss  of  energy  and  backwardness,  dulness  and 
stupidity  at  school  are  characteristic.  The  habit  of  mak- 
ing facial  grimaces  may  be  cured  by  removal  of  adenoids 
and  tonsils. 

Foul  breath  is  often  due  to  accumulated  secretions  re- 
tained in  diseased  tonsils.  It  is  unnecessary  to  refer  again 
to  the  dangers  resulting  from  decayed  teeth,  or  infections 
about  the  teeth  or  Riggs'  disease,  as  these  should  be 
remedied  by  constant  cleanliness,  and  may  be  prevented 
by  visits  to  the  dentist  at  monthly  intervals  for  thorough 
removal  of  tartar  and  polishing  of  the  teeth  so  that  no 
foreign  substances  will  adhere  to  them.  Decayed  teeth 
and  Riggs'  disease  require  special  treatment.  As  noted 
above,  an  x-ray  examination  of  the  jaws  is  the  only  certain 
method  of  determining  the  presence  of  diseased  teeth  in 
doubtful  cases.  The  presence  of  crowns  on  roots  in  which 
there  is  any  infection  may  favor  general  disease  by  per- 
mitting absorption  of  germs  or  their  poisons  into  the  blood. 

Chronic  inflammation  of  the  gall-bladder  and  appendix 
also  call  for  surgery,  as  no  other  treatment  is  of  value. 
But  while  the  disturbance  of  digestion  and  local  complica- 
tions (see  Cancer,  p.  174)  are  chiefly  feared,  the  danger  of 
permanent  damage  to  the  heart,  kidneys,  and  other  internal 
organs  (owing  to  germs  from  these  organs  set  free  in  the 
blood)  is  frequently  neglected.  Inflammation  of  the  fe- 
male organs  and  of  the  urinary  apparatus  in  both  sexes 
must  receive  appropriate  treatment  to  avoid  complication 
of  the  systemic  diseases  we  have  noticed.  Occasionally 
some  unusual  local  infection,  as  in  the  case  recorded  by 
Billings,  where  the  formation  of  pus  about  an  ingrowing 
toe-nail  led  to  an  attack  of  rheumatic  fever,  may  be  respon- 
sible for  serious  general  disease  and  must  not  be  overlooked. 

The  gist  of  the  whole  matter  is  that  some  apparently 


1 58  THE    PREVENTION  'OF   DISEASE 

trivial  local  diseases  about  the  mouth  and  throat  may  have 
the  most  far-reaching  and  important  consequences,  and 
that  local  infections  in  any  part  of  the  body  have  the  same 
significance  and  should  never  be  permitted  to  persist 
untreated.  Whoever  is  a  sufferer  from  such  chronic  ail- 
ments as  chronic  heart,  joint,  or  kidney  disease  should  be 
thoroughly  examined  from  head  to  foot — literally — for 
some  source  of  local  infection,  and  all  the  modern  tests, 
such  as  the  x-ray,  microscope,  test-meals  followed  by 
emptying  the  stomach,  etc.,  may  be  necessary  to  discover 
the  cause. 

But  still  more  to  the  point  is  it  that  persons  having 
one  of  the  local  diseases  about  the  throat  or  elsewhere 
should  seek  its  removal  before  serious  organic  disease 
in  other  parts  of  the  body  is  secondarily  caused  thereby. 
Because  one  has  had  enlarged  and  diseased  tonsils  for 
years,  and  has  escaped  any  of  the  direful  consequences 
herein  described,  is  no  proof  of  their  harmlessness.  Parents 
are  apt  to  point  to  themselves  as  examples  when  urged  to 
have  similar  faults  remedied  in  their  children.  Experience 
(of  the  profession)  teaches  "one  swallow  maketh  not 
summer." 

Riggs'  Disease. — We  have  in  another  place  (see  page 
22)  discussed  abscess  formation  about  the  roots  of  teeth, 
or  between  the  roots  and  the  gums,  in  pyorrhea  or  Riggs' 
disease.  The  abscesses  at  the  very  tip  of  the  roots,  which 
occur  so  commonly  in  teeth  in  which  the  nerve  has  been 
killed,  can  only  be  certainly  discovered  by  x-ray  pictures. 
Dentists  have  been  teaching  their  patients  that  all  teeth 
should  be  saved  when  possible.  But  these  teeth  abscessed 
at  the  end  of  the  roots  may  give  no  pain  and  yet  be  the 
means  of  causing  serious  disease  from  absorption  of  pus 
into  the  blood. 

Dentists  must  change  their  methods,  and  not  wait  until 


LOCAL    TROUBLES    AS    SOURCE    OF    SERIOUS    DISEASES      159 

a  physician  finds  some  secondary  disease  in  joints,  heart, 
etc.,  due  to  a  slow  absorption  of  pus  gerirfs  from  abscessed 
teeth  which  has  been  going  on  probably  for  years.  They 
must  take  x-ray  plates  of  teeth  in  adults  as  a  routine  prac- 
tice so  as  to  avoid  waiting  until  irreparable  damage  has 
been  done.  They  must  also  alter  their  principles  about 
saving  teeth,  because  in  many  cases  only  extraction  will 
cure.  In  treating  dead  teeth  with  abscess  at  their  roots 
by  boring  down  through  the  tooth,  as  has  been  the  custom, 
it  has  been  found  by  the  x-ray,  and  by  pus  later  breaking 
out  through  the  gums,  that  such  treatment  has  often  not 
been  successful. 

Finally,  it  may  be  reasonably  objected  that  we  make 
much  ado  about  nothing  when  a  large  proportion  of  human 
kind  have  infections  about  their  teeth  and  remain  healthy. 
It  can  only  be  said  that  unless  all  of  us  had  possessed  great 
natural  resistance  against  infections  we  would  not  now  be 
alive. 

The  large  percentage  of  sufferers  from  the  remote  effects 
of  mouth  infections  is  only  just  beginning  to  be  appreciated 
by  the  profession,  while  about  ten  years  more  will  be  re- 
quired to  educate  the  public  in  this  matter. 


CHAPTER  VIII 

THE  PREVENTION  OF  CANCER 
INTRODUCTORY  NOTE 

Cancer  of  the  lip,  tongue,  and  inside  of  the  mouth  is  largely  pre- 
ventable. It  occurs  in  smokers  and  in  those  with  rough  teeth  who 
do  not  take  proper  care  of  their  mouths.  Syphilis  is  present  in  a 
small  percentage  of  cases.  The  precancerous  conditions  usually 
consist  in  the  appearance  of  one  or  more  white  spots  or  patches  or 
ulcers  in  the  mouth;  or,  on  the  lip,  of  a  small  black  area  (burn),  or 
a  thickening  or  warty  growth.  These  commonly  produce  some 
pain  or  discomfort. 

If  smoking  is  immediately  stopped,  the  teeth  put  in  order,  and 
if  saleratus  is  used  frequently  as  a  mouth-wash  the  trouble  may 
heal  at  once.  If  it  does  not  heal  within  two  or  three  weeks  the  dis- 
eased area  should  be  cut  out  by  a  competent  surgeon  who  will 
know  whether  or  not  to  remove  the  neighboring  glands. 

Cancer  about  the  mouth  may  thus  be  avoided  in  most  cases  by 
following  these  simple  rules. 

Cancer  of  the  skin  originates  in  pre-existing  tumors,  moles,  birth- 
marks, warts,  and  scaly,  thickened  patches  (keratosis).  These, 
as  a  rule,  should  be  removed  with  a  knife  or  cautery,  including  a 
good  margin  of  healthy  skin,  and  the  removed  tissue  should  be 
then  examined  microscopically.  Any  local  skin  defect — as  an  ulcer, 
wart,  tumor,  scaly,  thickened  patch,  or  discharging  aperture  on 
the  .skin — must  be  regarded  as  precancerous.  It  matters  little 
whether  the  cause  be  injury,  tuberculosis,  or  syphilis  of  the  skin, 
or  keratosis  due  to  exposure  to  the  sun  or  lead  or  arsenic,  the  possi- 
bility of  cancer  is  about  the  same.  If  such  areas  are  healed  or  cut 
out  cancer  may  be  avoided.  Cancer  of  the  skin,  therefore}  is  a  pre- 
ventable disease. 

Cancer  of  the  Breast. — Not  knowing  its  cause,  we  have  no  means 
of  preventing  or  treating  it  until  a  lump  appears  in  the  breast. 
160 


THE  PREVENTION  OF  CANCER  161 

When  such  lumps  are  at  once  removed  on  their  discovery  half  will 
be  found  benign  (not  cancerous).  Only  1  per  cent,  of  lumps  in  the 
breast  are  malignant  under  twenty-five  years  of  age.  Every  lump 
in  the  breast  of  a  female  over  twenty  years  should  be  explored. 
When  benign,  its  removal  will  absolutely  prevent  cancer. 

The  chances  of  permanent  recovery  in  true  breast  cancer — if 
removed  on  its  discovery— depend  upon  its  kind.  If  adenocarcinoma, 
recovery  should  occur  in  96  per  cent,  of  cases;  if  a  cancer  cyst,  or  in 
the  scirrhous  or  medullary  form,  86  per  cent,  have  been  permanently 
cured— providing  the  growth  is  removed  by  the  complete  operation 
as  soon  as  discovered.  The  chances  of  recovery  grow  less  and  less 
as  the  delay  is  more  and  more  protracted  until  the  cancer  is  in- 
curable from  the  extent  of  the  local  or  general  involvement  (metas- 
tasis). 

When  all  the  women  have  this  knowledge  and  seek  the  physician 
at  once,  and  when  he  acts  promptly,  and  the  proper  surgery  is  imme- 
diately done,  the  number  of  deaths  from  cancer  of  the  breast  will  be 
tremendously  decreased. 

Cancer  of  the  Thyroid. — If,  in  individuals  over  twenty,  every 
irregular  lump  of  the  thyroid  gland  (situated  directly  below  the 
"Adam's  apple"  in  the  throat)  was  removed  as  soon  as  found 
cancer  in  this  region  would  be  practically  unknown.  Cancer 
here  begins  as  a  benign  growth,  and  if  removed  before  the  sur- 
rounding parts  are  involved,  general  or  local  recurrence  will  not 
occur. 

Sarcoma  of  Soft  Parts. — Lumps  under  the  skin  in  all  parts  of  the 
body  should  be  removed,  as  it  is  impossible  to  tell  the  benign  from 
the  malignant.  No  harm  is  done  by  removing  benign  growths  and 
there  will  never  be  a  better  time  to  remove  sarcomata.  Surgery 
must  be  thorough  and  the  growth  must  be  removed  surrounded  by 
a  wide  margin  of  healthy  tissue — not  merely  shelled  out. 

Sarcoma  of  Bone. — Early  intervention  offers  the  only  hope  of 
cure.  Pain  at  one  point  in  a  bone  or  joint,  especially  after  injury 
(continuous  or  at  a  later  date),  demands  x-ray,  blood,  and  urine 
examination.  In  my  experience  the  first  thing  to  be  done  is  that 
done  last  and  too  late  for  the  cure  of  malignant  disease  of  bone  or 
joint. 

Cancer  of  the  womb  is  largely  preventable.  The  majority  of  cases 
begin  at  the  outlet  (cervix)  in  women  who  have  borne  children. 
Every  woman  should  keep  a  careful  watch  and  record  of  the  char- 
acter and  periods  of  menstruation,  and  on  observing  anything  un- 
11 


162  THE   PREVENTION   OF  DISEASE 

usual,  should  submit  to  a  careful  examination.  The  reappearance 
of  bleeding  after  the  change  of  life  is  a  message  requiring  immediate 
attention.  Doctors  may  also  prevent  cancer  of  the  womb  by  better 
obstetrics,  by  careful  examination  of  women  after  childbirth,  by 
early  repair  of  lacerations,  by  correcting  displacements  and  endo- 
metritis — thus  avoiding  precancerous  conditions. 

Cancer  of  the  Stomach. — If  it  is  true  that  a  large  percentage  of 
cancers  of  the  stomach  develop  on  pre-existing  ulcer,  then  it  is  a 
preventable  disease.  Ulcer  of  the  stomach  is  regarded  by  patients 
as  "indigestion"  and  does  not  receive  early  expert  attention,  and 
many  doctors  begin  with  treatment  instead  of  thorough  examina- 
tion. I  believe  the  best  treatment  in  simple  gastric  ulcer  consists 
in  prolonged  rest  and  a  semistarvation  diet. 

Cancer  of  the  Colon  (Large  Intestine). — This  may  not  be  a  pre- 
ventable disease,  but  if  recognized  and  removed  early  it  is  one  of 
the  most  curable  forms  of  cancer.  In  the  left  colon  acute  obstruc- 
tion leads  to  early  intervention,  but  in  the  right  colon  the  fluid 
contents  do  not  favor  obstruction  and  discovery  of  cancer  is  late. 
However,  patients  do  have  symptoms  for  ir.onths  and  years  before 
obstruction,  and  wide-spread  growth  occurs,  and  proper  examination 
in  this  period  will  bring  out  indications  for  operation. 

Cancer  of  the  Rectum  and  Lower  Bowel  (Sigmoid). — The  early  dis- 
covery of  this  condition  rests  largely  with  the  doctor  in  making  an 
examination  by  finger  or  instrument  (proctoscope)  because,  as  a  rule, 
the  patient  seeks  advice  early. 

Many  types  of  cancer  are  preventable  and  most  malignant 
growths  may  be  recognized  early.  In  this  period  surgery  offers  a 
large  probability  of  permanent  cure.  The  difficult  problem  is  how 
to  convey  the  information  to  millions  instead  of  hundreds,  and  how 
to  get  them  to  act  on  this  information.  A  book  of  this  character 
will  have  a  large  influence  for  good — especially  among  the  reading 
public  and  profession.  My  own  intensive  study  of  the  educa- 
tional propaganda  has  forced  me  to  conclude  that  the  individual 
doctor  is,  on  the  whole,  the  best  medium  for  spreading  this  knowl- 
edge. He  should  feel  that  it  is  part  of  his  professional  duty  to 
educate  all  individuals  who  seek  his  advice  about  personal  hygiene, 
and  should  give  them  that  information  which  will  allow  them  to 
recognize  possible  diseases  early. 

JOSEPH  COLT  BLOODGOOD. 


THE  PREVENTION  OF  CANCER  163 

This  matter  I  regard  as  by  far  the  most  important  and 
vital  subject  treated  in  this  book,  since  it  has  been  the 
predominant  thought  and  endeavor  of  medical  men 
throughout  the  world  for  many  years. 

Only  within  the  past  six  months  have  articles  appeared 
on  this  subject  by  three  of  the  leading  surgeons  of  America 
— Drs.  Mayo,  Bloodgood,  and  Rodman. 

While  the  essential  cause  of  cancer  is  unknown,  many 
facts  of  vital  value  have  come  to  light.  Thus,  cancer  is 
certainly  not  a  blood  disease  or  disorder  of  the  general 
system,  but  is  a  truly  local  trouble. 

Maurice  Richardson's  maxim  that  every  cancer  is  cur- 
able at  some  stage  of  its  existence  is  now  generally  ac- 
cepted. Then,  again,  it  is  known  that,  whether  cancer  is 
due  to  germs  or  not,  local  irritation  is  the  essential  first 
stage  of  cancer,  or  what  has  been  called  the  precancerous 
stage.  The  precancerous  stage  may  merely  mean  a  state 
of  local  chronic  irritation  anywhere  in  the  body,  although, 
strictly  speaking,  it  should  describe  the  earliest  microscopic 
changes  in  the  tissues  recognized  as  cancer.  We  shall  use 
the  term  in  its  wider  rather  than  in  this  stricter  interpre- 
tation. The  precancerous  conditions  are  becoming  very 
well  known,  and  the  surgery  of  such  conditions  is  safe  and 
their  removal  by  this  means  accomplishes  a  certain  cure 
of  cancer  in  practically  all  cases.  This  is  the  present 
hope  which  the  medical  profession  has  to  offer,  and  in  so 
far  as  it  is  accepted  and  acted  upon  by  the  profession,  in  so 
far  will  cancer  disappear,  for  it  is  a  preventive  rather  than 
a  curative  measure.  Cancers  may  be  divided  into  four 
classes : 

(1)  The  class  in  which  a  certain  diagnosis  cannot  be  made 
before  operation.  (2)  The  class  in  which  diagnosis  is 
reasonably  probable  before  operation.  (3)  The  class  in 
which  the  disease  is  so  far  advanced  that  there  is  extension 


164  THE    PREVENTION   OF   DISEASE 

to  some  of  the  neighboring  glands,  but,  nevertheless, 
the  case  would  be  considered  best  treated  by  operation. 
(4)  The  inoperable  class,  in  which  the  disease  has  be- 
come general  and  in  which  local  removal  has  become 
impossible.  J 

If  all  cases  of  cancer  could  be  treated  in  the  precancerous 
stage  (of  the  first  class)  the  cures  would  be  certain  and 
recurrence  would  be  unknown.  These  conditions  are 
recognized  at  the  time  of  operation  by  the  microscopic 
section,  and  occasionally  by  the  appearance  and  feel  of 
the  tissues  removed.  Thus,  it  is  not  uncommon  to  dis- 
cover cancer  beginning  in  an  inflamed  appendix,  gall- 
bladder, ulcer  of  the  stomach,  or  in  a  lump  in  the  breast 
by  microscopic  examination  after  removal  which  could  not 
by  any  means  be  determined  prior  to  operation.  Such 
cases  are  always  cured  if  they  are  in  strictly  the  precan- 
cerous stage,  but  as  the  patients  are  ignorant  of  their  con- 
dition, often  not  being  told  after  the  operative  discovery, 
it  is  impossible  for  them  to  realize  that  they  have  been 
cured  of  cancer,  and  the  public  cannot  be  impressed  by 
such  cures. 

In  the  second  class  of  cases  the  chances  of  recovery  are 
immensely  greater  than  the  third  class.  For  example, 
in  cancers  where  the  disease  has  extended  to  the  neighbor- 
ing glands  the  chances  of  recovery  are  diminished  by  75 
per  cent.  Thus,  in  cancer  of  the  breast  the  returns  at  the 
Mayo  and  Johns  Hopkins  clinics  show  that  before  any 
glandular  lumps  have  formed  in  the  armpits  about  80  per 
cent,  of  cases  are  well  five  years  after  operation.  But 
when  the  operations  are  done  after  these  lumps  in  the 
armpits  have  occurred,  the  percentage  of  five-year  cures  is 
reduced  to  25  per  cent.  We,  as  a  profession,  are  as  much 
to  blame  as  the  laity  for  the  fearful  frequency  of  cancer. 
There  are  some  80,000  deaths  from  cancer  annually  in  the 


THE  PREVENTION  OF  CANCER  165 

United  States,  and  probably  half  of  them  might  be  pre- 
vented with  the  knowledge  we  have  today — by  attacking 
the  precancerous  conditions  to  be  described.  In  England, 
where  the  statistics  have  been  kept  more  accurately  for  a 
longer  period  than  in  the  United  States,  it  has  been  found 
that  1  in  every  7.4  women  and  1  in  every  9.7  men  over 
thirty-five  die  of  cancer  (Hoffman). 

The  same  statistics  apply  in  this  country,  according  to 
the  leading  surgeons.  That  cancer  kills  1  in  7  women 
and  1  in  11  men  over  thirty-five  years  of  age  is  common 
knowledge  (Bainbridge).  In  the  United  States  in  1912 
of  deaths  over  thirty,  1  in  11.5,  and  of  deaths  over  forty, 
1  in  every  10.5  persons  was  from  cancer  (Taylor).  The 
proportion  is  larger  in  women  on  account  of  their  liability 
to  cancer  of  the  "womb  and  breast.  One-third  of  all  the 
cases  of  cancer  are  in  the  stomach. 

The  researches  of  the  Pennsylvania  Cancer  Commission 
shed  a  strong  light  on  the  reasons  for  the  unfortunate 
cancer  condition. 

They  gathered  together  valuable  statistics  concerning 
400  cases  of  cancer,  and  found  that  68  per  cent,  of  operable 
cancers  were  on  the  surface  or  in  cavities,  as  in  the  outlet 
of  the  womb  and  in  the  mouth,  where  they  could  be  read- 
ily seen,  and  the  remainder  of  the  operable  cancers  were 
deeply  seated,  but  in  both  groups  over  a  year  on  the 
average  had  elapsed  after  the  patients  had  consulted 
their  family  physicians  before  they  were  referred  to  the 
surgeon.  As  it  has  been  discovered  that  about  this  time, 
or  less,  is  required  for  extension  into  the  neighboring 
glands,  so  that  they  may  be  felt  as  lumps  by  the  ex- 
amining doctor,  and  as  this  is  the  chief  reason  why 
physicians  delay  in  such  cases — to  make  a  certain  diagno- 
sis— the  cause  of  the  awful  result  is  easily  seen. 

By  this  watchful  course,  which  is  only  made  possible  by 


166  THE   PREVENTION   OF  DISEASE 

the  patient's  ignorance  and  inherent  dread  of  operation, 
the  doctor  has  caused  the  patient  to  have  but  one  chance 
of  cure  in  four,  instead  of  having  three  chances  of  cure  in 
four,  as  he  would  have  had  before  the  diagnosis  became 
absolutely  certain  and  plain  to  the  veriest  medical  tyro. 
Therefore  when  a  doctor  waits  in  suspected  or  possible 
cancer  for  all  symptoms  to  develop  so  that  the  diagnosis 
becomes  absolute,  he  is  almost  criminal.  The  early  pre- 
cancerous  conditions  must  be  doubtful  to  be  permanently 
and  successfully  removed. 

Nothing  is  lost  by  operating  in  this  stage  except  the 
comfort  of  the  patient,  and  what  is  this  beside  a  possible 
life  of  pain  and  death  from  cancer?  Surgeons  are  daily 
confronted  with  the  results  of  watchful  waiting  in  cancer, 
and  these  cases  constitute  the  dread  of  his  career. 

In  13  per  cent,  of  cases  of  cancer  of  the  breast  the  family 
physician  advised  watchful  and  suicidal  waiting,  and  in  20 
per  cent,  of  the  cases  of  cancer  of  the  stomach  and  womb 
similar  bad  advice  was  given,  and  no  local  examination  in 
either  disease  was  made  in  10  per  cent,  of  the  patients. 

At  Johns  Hopkins  it  has  been  found  that  84  per  cent, 
of  the  cases  of  cancer  of  the  breast  do  not  come  to  operation 
until  the  glands  in  the  armpits  are  enlarged  so  that  lumps 
may  be  felt  there.  At  present,  operation  leads  to  from  10 
to  50  per  cent,  of  cures  in  cases  of  operable  cancer  of  all 
kinds,  while  25  per  cent,  of  cases  of  cancer  of  the  bowel  and 
stomach  are  curable,  and  50  per  cent,  of  cancers  of  the 
breast — the  cures  being  based  on  the  patients  remaining 
well  five  years  after  the  operation  (Rodman). 

But  some  cancers  are  more  readily  cured  by  operation 
than  others.  Thus,  at  the  Mayo  clinic  93  per  cent,  of  the 
cases  of  cancer  of  the  lip  are  reported  as  cured  by  their 
very  thorough  operation.  If  surgeons  should  refuse 
to  operate  in  advanced  cases  of  cancer,  operations  for  all 


THE  PREVENTION  OF  CANCER  „          167 

cancers  would  be  much  more  readily  and  profitably  ac- 
cepted by  the  public.  Deaths  in  advanced  cancer  do  not 
occur  from  the  effects  of  the  operation  in  most  cases,  but 
from  the  disease.  But  such  deaths  deter  early  cases  from 
operation  because  patients  recall  the  death  of  friends  from 
cancer  after  operation  and  wrongly  attribute  the  result 
to  the  operation.  If  surgeons  only  operated  on  precancer- 
ous  and  early  cancerous  conditions,  the  results  would  be  so 
remarkable  that  the  benefit  to  the  world  would  be  ines- 
timable— as  object  lessons.  But  humanity  demands  a 
fighting  chance,  and  alleviation  of  suffering  is  often  the  only 
object  sought  now  in  truly  inoperable  cases. 

It  is,  indeed,  a  fearful  state  of  affairs  which  is  reported 
by  leading  surgeons,  as  by  Childe,  that  90  per  cent,  of  the 
cases  of  cancer  of  the  womb  are  so  far  gone  as  not  to  be 
operable  when  they  first  come  to  him,  and  that  the  same 
percentage  of  patients  with  cancer  of  the  stomach  are  inop- 
erable when  they  first  present  themselves  to  Munroe  and 
Bottomley.  Dr.  William  J.  Mayo  finds  that  one-third  of 
the  cases  of  cancer  of  the  stomach  coming  to  him  are  cur- 
able by  operation,  but  in  his  clinic  many  cases  are  dis- 
covered by  elaborate  means  of  diagnosis  in  patients  seeking 
relief  for  various  diseases.  His  statistics  are  the  most 
encouraging  in  this  disease — 38  per  cent,  of  the  patients 
operated  on  for  cancer  of  the  stomach  are  well  at  the  end  of 
three  years,  and  25  per  cent,  are  alive  and  well  at  the  end  of 
five  years. 

The  results  of  the  treatment  of  all  kinds  of  cancer  would 
be  infinitely  better  today  if  patients  would  apply  for  relief 
at  an  early  stage  of  the  trouble,  and  it  is  the  object  of  this 
article  to  point  out  the  precancerous  conditions  which 
should  warn  the  patient  to  seek  immediate  surgical  advice. 

Of  course,  in  the  precancerous  conditions  of  the  skin  and 
surface  of  the  body  recognition  is  the  rule  in  the  earliest 


168  THE    PREVENTION    OF   DISEASE 

stages,  and  these  should  be  cured  by  the  slightest  operations 
and  with  the  best  chance  for  certain  permanent  cures. 

Local  irritation  as  a  cause  for  cancer  has  recently  been 
forcibly  presented  in  an  address  before  the  American  Sur- 
gical Association  by  Dr.  W.  J.  Mayo.  In  it  he  brought 
forward  many  known  forms  of  local  irritation  productive  of 
cancer,  and  mentioned  the  betel-nut  chewers  of  India. 
Cancer  of  the  mouth  is  so  common  from  the  irritation  of 
this  substance  that  in  976  cases  of  cancer  from  all  the  causes 
in  the  Madras  General  Hospital  nearly  50  per  cent,  were 
located  in  the  mouth.  And,  again,  the  influence  of  heat 
irritation  was  adduced,  as  exemplified  by  the  frequency  of 
cancer  on  the  shins  of  locomotive  drivers,  and  in  the  natives 
of  Kashmir,  who  wear  hot  Kangri  fire  baskets  next  the  skin 
of  the  lower  abdomen  in  winter.  Among  some  2020  tumors 
in  the  Kashmir  Mission  Hospital  there  were  363  cancers 
caused  by  the  burns  of  these  baskets  on  the  abdomen. 
Constant  exposure  to  the  x-rays  has  been  a  notable  source  of 
cancer  among  medical  men.  Local  irritation,  or  some 
form  of  skin  trouble,  preceded  every  one  of  the  820  cases 
of  cancer  of  the  skin  and  mucous  membrane  reported  by 
Professor  Bloodgood.  Malignant  tumors  frequently  arise 
from  blows.  Dr.  Murphy  states  that  a  single  blow  on  the 
breast  is  not  uncommonly  followed  by  the  appearance  of 
cancer  in  women.  Warts  and  dark  moles  on  the  skin,  es- 
pecially when  subjected  to  irritation  through  rubbing  of  the 
clothing,  scratching,  or  pressure,  are  well  recognized 
precancerous  conditions;  this  fact  was  emphasized  in  a 
(now  classical)  paper  by  Professor  Keen  delivered  in  1904. 
He  showed  that  the  cancerous  change  frequently  occurred 
some  thirty,  forty,  or  even  fifty  years  after  the  existence  of 
the  wart  or  mole,  and  that,  as  there  was  no  special  reason 
why  the  growth  should  be  removed  today  rather  than 
tomorrow,  or  this  year  rather  than  next,  it  was  allowed 


THE  PREVENTION  OF  CANCER  169 

to  remain  until  some  local  irritation,  such  as  combing  a 
wart  on  the  head,  or  through  the  pressure  of  a  hat  or  rub- 
bing of  a  collar  on  a  mole  of  the  neck,  the  wart  or  mole 
suddenly  took  on  a  growth  which  in  most  cases  was  malig- 
nant. The  moral  is  to  remove  such  at  the  first  opportunity, 
but  if  there  are  many  warts  or  dark  moles  on  the  body  the 
subject  may  wait  until  there  is  the  slightest  sign  of  irrita- 
tion or  growth  in  any  wart  or  dark  mole,  when  it  should  be 
immediately  removed  by  a  surgeon.  The  habit  of  par- 
tially removing  such  growths  by  scraping  them  off  the 
skin  and  leaving  the  base  is  illustrated  by  a  case  coming 
to  the  attention  of  the  author,  where  a  mole  became  irri- 
tated and  was  partially  removed,  and  a  general  malignant 
disease  of  all  the  internal  organs  followed  within  a  month 
or  two. 

Warts  or  moles  should  be  removed  properly  with  their 
skin  bases  by  a  surgeon  after  the  injection  of  cocain. 
Cancer  of  the  lip  is  rarely  seen  except  in  smokers,  and  is 
thought  to  be  due  to  the  heat  or  pressure  of  the  pipe  stem. 
In  the  mouth  white  patches  form  on  the  tongue  and  inside 
of  the  lips  and  cheeks — more  usually  on  the  tongue  in 
smokers — and  this  condition  quite  often  becomes  cancerous 
unless  smoking  is  stopped  and  the  white  patches  are 
cauterized.  The  constant  taking  of  hot  food  or  drink  may 
produce  dangerous  irritation  in  the  mouth. 

Parts  subjected  to  blows  should  be  carefully  watched 
and  operation  should  be  done  on  the  slightest  sign  of  malig- 
nant disease.  Coley  has  found  a  history  of  previous  injury 
in  about  one-third  of  328  cases  of  cancer. 

Cancer  of  the  breast,  so  common  in  women,  has  a  very 
bright  outlook  when  the  tumor  is  removed  early — before 
spread  of  the  disease  into  the  surrounding  tissue  and  the 
glands  in  the  armpits — as  we  have  seen.  Any  lump  in  the 
breast  demands  the  immediate  attention  of  a  surgeon. 


170  THE    PREVENTION   OF   DISEASE 

There  are  no  means  by  which  the  innocent  lump  may  be 
distinguished  from  the  malignant  tumor  in  many  cases. 
The  inflammatory  lump  or  the  innocent  tumor  frequently 
become  malignant  in  time. 

It  is  common  practice  for  a  physician  to  find  a  movable 
lump  in  the  breast  of  a  young  woman,  and  tell  her  to  come 
back  in  six  months  or  some  other  time,  adding  there  is 
nothing  he  can  see  to  worry  about.  There  is  nothing  that 
anybody  can  see  to  worry  about,  but  there  may  be  some- 
thing very  serious  that  no  one  can  see  or  feel  to  cause  worry. 
If  such  a  lump  is  removed  and  found  innocent  the  opera- 
tion is  neither  dangerous  nor  disfiguring,  and  the  patient 
has  the  satisfying  knowledge  that  there  is  no  danger  from 
that  source  in  the  future.  If  it  is  allowed  to  remain,  danger 
threatens,  and  the  lump  ought  to  be  a  continuous  cause  of 
anxiety.  A  typic  cancer  occurs  in  a  woman  of  middle  age 
or  over,  is  situated  in  the  upper  and  outer  part  of  the 
breast,  and  is  not  painful  or  tender  at  first,  but  later  may 
become  painful.  After  a  time  the  tumor  becomes  fixed 
in  the  skin  and  may  cause  dimpling  of  the  skin  or  a 
drawing  in  of  the  nipple,  and  then  the  tumor  is  not  freely 
movable.  The  tumor  is  best  felt  not  by  pinching  up  a 
fold  of  the  breast,  but  by  pressing  the  surface  of  the  breast 
with  the  open  palm  against  the  chest  while  the  subject  is 
lying  flat  on  her  back. 

But  there  are  all  kinds  of  exceptions  to  this  description. 
A  sore  on  the  skin  or  irritation  of  the  skin  about  the 
nipple,  or  a  discharge  from  the  nipple,  should  lead  a  woman 
to  consult  a  surgeon  at  once. 

Patients  in  their  twenties  may  have  cancer  of  the  breast, 
it  may  occur  in  any  part  of  the  breast,  pain  may  be  the 
first  symptom,  it  may  be  freely  movable  and  not  possess 
the  slightest  suggestion  of  cancer,  or  it  may  appear  inflam- 
matory. At  the  risk  of  repetition,  for  it  cannot  be  too 


THE  PREVENTION  OF  CANCER  171 

strongly  emphasized,  a  woman  with  a  lump  in  her  breast 
should  go  at  once  to  a  competent  surgeon  for  advice.  The 
modesty  which  causes  the  patient  to  hide  her  trouble  until 
it  begins  suddenly  to  grow  apace  is  terribly  false  and  mis- 
taken. A  tumor  of  the  breast  which  has  caused  no  trouble 
for  months  or  years,  and  then  begins  to  rather  rapidly  en- 
large is  almost  invariably  cancer,  and  the  chances'  are  that 
the  surrounding  tissue  will  be  so  invaded  that  the  likelihood 
of  cure  will  be  much  reduced.  Almost  one-third  of  the 
patients  with  cancer  of  the  breast  now  come  to  surgeons 
when  the  growth  has  already  advanced  to  a  stage  when 
operation  really  offers  no  hope  of  cure. 

Cancer  of  the  Stomach. — As  we  have  seen,  the  stomach 
is  the  most  common  situation  of  cancer  in  the  whole  body; 
one-third  of  all  the  cancers  originate  in  this  organ.  Dr. 
Mayo  has  pointed  out  that  cancer  of  the  stomach  is  un- 
common in  animals  and  savages,  that  there  is  something 
in  the  habits  or  preparation  of  food  which  favors  the 
occurrence  of  cancer  in  civilized  man. 

Cancer  of  the  stomach  can  be  less  readily  diagnosed  in  its 
earlier  stages  than  any  other  common  form,  so  that  at 
present  but  about  one-third  of  the  cases — at  the  best — 
come  to  the  surgeon  in  time  for  successful  removal  of  the 
growth.  But,  as  we  have  noted,  ulcer  of  the  stomach  is 
the  most  frequent  precancerous  condition,  and  a  previous 
history  of  ulcer  of  the  stomach  is  found  in  more  than  half 
the  cases  by  some  authorities,  while  positive  evidence  of 
ulcer  as  a  cause  of  cancer  has  been  proved  by  microscopic 
examination  in  62  per  cent,  of  cancers  of  the  stomach  re- 
moved during  several  years  at  the  Mayo  clinic. 

So  that  ulcer  of  the  stomach  must  be  treated  to  avoid 
cancer.  While  this  book  is  not  intended  as  a  text-book 
in  medicine,  a  few  words  as  to  ulcer  of  the  stomach  may  not 
be  amiss.  Many  cases  of  ulcer  were  formerly  called  ner- 


172  THE   PREVENTION   OF   DISEASE 

vous  dyspepsia.  The  chief  distinguishing  feature  is  the 
occurrence  of  pain  at  a  regular  time  after  eating — one-half 
hour  to  five  hours — which  is  relieved  by  food,  vomiting, 
or  saleratus,  and  is  accompanied  with  much  gas,  heart- 
burn, and  acidity.  Attacks  occur  during  periods  for  years 
and  there  are  long  intervals  of  good  health  intervening. 
Medical  and  surgical  cure  of  chronic  ulcer  is  possible,  and 
such  symptoms  should  not  be  regarded  lightly,  if  only  be- 
cause cancer  may  be  the  ultimate  end. 

Therefore  cancer  appears  in  persons  who  are  having 
symptoms  of  ulcer  of  the  stomach,  in  those  who  have  been 
well  for  many  years  after  a  former  history  of  ulcer,  and  in 
about  half  of  the  cases  the  symptoms  of  cancer  come  out  of 
a  clear  sky  in  persons  of  middle  age  who  have  previously 
enjoyed  good  health.  This  fact  is  one  of  the  most  sus- 
picious possible — i.  e.,  the  occurrence ,  of  symptoms  of 
continuous  severe  indigestion  in  one  of  middle  age  or  past 
who  has  previously  been  free  from  stomach  trouble. 

Thus,  the  aggravation  of  previous  symptoms  of  stomach 
trouble,  or  the  sudden  appearance  of  them  in  a  person  past 
young  adult  life,  are  equally  suggestive.  The  general  con- 
dition is  as  characteristic  as  are  stomach  symptoms. 
The  patient  begins  to  lose  weight,  strength,  appetite  and 
energy,  suffers  from  mental  depression  and  weariness,  and 
has  a  sense  of  "impending  evil."  There  is  pallor  about  the 
nose,  eyes  and  mouth,  and  the  face  has  a  pinched  expres- 
sion (Graham).  Pain  in  the  stomach  may  be  absent,  but 
usually  there  is  a  continuous  indescribable  feeling  of  dis- 
tress, worse  after  eating,  with  the  presence  of  much  gas 
and  heartburn. 

Vomiting  of  undigested  food  many  hours  or  days  after 
it  has  been  taken  is  particularly  suggestive,  especially  if 
some  dark  blood  is  present. 

The  patient  may  feel  a  movable  lump  in  the  region  of  the 


THE  PREVENTION  OF  CANCER  173 

stomach,  and  this  tumor  may  be  evidence  of  a  rather  favor- 
able case  for  operation. 

The  new  use  for  the  x-ray  in  the  examination  of  the 
stomach  within  the  last  few  years  has  been  of  much  aid  in 
the  diagnosis  of  ulcer  and  cancer,  but  should  never  be 
employed  apart  from  physical  examination  by  an  expert 
in  stomach  troubles,  as  the  findings  of  the  x-ray  must  be 
construed  in  the  light  of  bedside  experience. 

Since  cancer  of  the  womb  is  common,  and  the  majority 
of  cases  (90  per  cent.)  come  to  the  surgeon  too  late  for 
satisfactory  cure,  the  importance  of  the  knowledge  of 
suggestive  signs  cannot  be  too  strongly  emphasized 
nor  too  quickly  acted  upon.  The  occurrence  of  local  irri- 
tation here  is  an  important  precancerous  condition;  that  is, 
the  existence  of  lacerations,  which  are  the  rule  following 
childbirth.  The  repair  of  these  is  then  always  essential, 
if  only  for  the  prevention  of  cancer,  although  they  are  a 
source  of  many  other  troubles.  Cancer  should  always  be 
thought  of  in  women  of  middle  age  (thirty-five  to  forty) 
when  there  is  irregular  flowing  following  severe  exertion  or 
at  other  times.  The  same  condition  is  common  during  the 
change  of  life,  and  this  causes  women  to  slight  the  symptom 
and  neglect  the  trouble  when  it  is  in  the  most  curable  stage. 
Women  should  always  consult  a  doctor  and  insist  on  a 
local  examination  in  any  case  of  irregular  flow,  even  if  it  be 
slight. 

If  such  occur  after  the  change  of  life  is  apparently  past 
the  demand  for  local  examination  is  even  more  urgent.  A 
colorless  or  brownish  watery  discharge,  with  or  without  un- 
pleasant odor,  is  another  suggestive  sign.  Pain  in  the 
lower  part  of  the  body  or  thighs  may  or  may  not  be  present, 
as  well  as  pain  and  irritability  of  the  bladder. 

The  repair  of  lacerations  following  childbirth  may,  there- 
fore, prevent  future  precancerous  conditions,  while  seeking 


174  THE    PREVENTION    OF   DISEASE 

advice  on  the  first  appearance  of  the  slightest  irregularities, 
as  suggested  above,  may  be  the  means  of  saving  the  pa- 
tient's life  in  early  middle  age  or  at  any  time  thereafter. 

In  the  abdomen  a  chronic  inflammation  of  the  appendix 
and  gall-bladder  may  lead  to  cancer  in  these  organs; 
particularly  is  this  so  in  the  case  of  the  gall-bladder. 
Operations  to  remove  these  organs  will,  therefore,  not  only 
cure  the  appendicitis  and  gall-bladder  trouble,  with  their 
accompanying  digestive  disturbances,  but  will  prevent  the 
possibility  of  future  cancer  in  these  parts.  £s^ 

Cancer  on  the  skin,  we  have  seen,  has  its  precancerous 
stage  in  irritation  of  some  already  existing  skin  troubles,  as 
warts,  pimples,  and  moles,  or  scaling  or  scurfy  patches  in 
old  persons.  This  remark  applies  especially  to  the  thick- 
ened, scaly  patches — perhaps  as  large  as  a  pea  or  bean — 
that  are  common  on  the  face,  ears,  or  hands  in  middle  age 
and  beyond.  The  scales  -are  white  or  brownish  and  come 
off — only  to  return  again.  Then  there  are  hard,  brown 
warty  patches  on  the  face  that  crumble  when  picked  off- 
only  to  reappear.  These  conditions  may  be  readily  re- 
moved by  freezing  with  carbonic  acid  snow  before  they 
become  cancerous.  Irritation  about  the  nose,  lips,  tongue, 
and  angles  of  eyes  should  receive  particular  attention  be- 
cause these  are  favorite  sites  of  cancer.  All  sores  and 
ulcers  must  be  treated  to  prevent  them  from  becoming 
chronic,  and  then  a  possible  source  of  cancer.  Cancer 
of  the  skin  occurs  more  often  on  the  face  and  head, 
in  elderly  men  on  the  site  of  skin  defects.  Cancer  of 
the  lip  is  most  frequent,  and  begins  in  men  over  forty 
on  the  under  lip  as  a  thickening  or  warty  growth  at 
the  margin  of  skin  and  mucous  membrane.  This  usu- 
ally is  produced  by  a  straight,  short-stemmed  pipe, 
as  more  likely  to  be  hot.  The  little  pea-sized  wart  or 
thickening  of  the  lip  becomes  raw  and  then  scabs  over,  but 


THE  PREVENTION  OF  CANCER  175 

does  not  heal  permanently.  After  three  or  more  months 
lumps  or  enlarged  glands  form  under  the  jaw,  but  when  this 
happens  the  proper  time  for  operation  is  past.  The  radical 
operation,  in  which  all  the  glands  in  the  upper  part  of  the 
neck  are  removed  before  they  are  invaded,  is  rewarded  by 
permanent  cure  in  almost  all  cases,  as  noted  above. 

A  small  thickening  or  abrasion  on  the  lower  lip,  persist- 
ing for  some  months  in  a  man  over  forty,  is  almost  sure  to 
be  cancer. 

Cancer  of  the  nose,  face,  eyelids,  forehead,  ear,  back  of 
the  hand,  etc.,  beginning  in  a  wart,  mole,  scurvy,  patch, 
or  red,  yellow,  or  pearly  pimple,  enlarges,  crusts,  and  then 
gradually  disappears,  melting  away  into  a  raw  ulcerated 
spot,  which  may  gradually  involve  the  surrounding  skin. 
The  ulcerated  or  excavated  raw  patch  has  raised,  pearly 
borders.  Its  growth  is  slow  and  several  years  may  be 
required  for  it  to  become  of  much  depth  or  size  and  extend 
all  over  the  face.  In  some  cases  the  original  wart,  mole, 
pimple,  or  scurvy  patch  may  grow  into  a  tumor,  which  later 
breaks  down  and  ulcerates,  and  in  other  cases  it  presents 
a  number  of  raw  projections  like  a  cauliflower.  Cancer 
of  the  tongue  is  quite  common,  and  starts  from  the  irrita- 
tion of  hot  and  cold  food,  an  irregular  and  sharp  tooth,  or 
the  white  patch  caused  by  excessive  smoking.  There  is  at 
first  a  crack  in  the  tongue  and  soon  a  raw  spot  or  ulcer  with 
a  thickened  base.  Almost  all  of  the  skin  cancers  are  quite 
susceptible  of  permanent  cure  in  the  beginning  by  removal 
with  the  knife  before  the  disease  has  permeated  into  the 
neighboring  glands.  Various  means  are  used  to  remove 
cancers  of  the  skin,  as  caustics,  x-ray,  radium,  freezing, 
etc.,  but  growths  can  be  removed  at  once  by  the  knife,  and 
only  by  this  measure  can  just  the  proper  amount  of  tissue 
be  destroyed  by  the  directing  hand  of  the  able  and  ex- 
perienced surgeon.  But  superior  to  this  and  all  other  cura- 


176  THE   PREVENTION   OF   DISEASE 

tive  means  is  the  removal  of  the  precancerous  stage  of 
cancer  of  the  skin  and  the  avoidance  altogether  of  the 
occurrence  of  the  naturally  dreaded  malignant  disease. 
re-Ray  and  radium  may  cure  skin  cancers,  but  they  should 
not  be  used  to  treat  deep-seated  or  early  growths  anywhere 
which  are  curable  by  the  knife  (Mayo).  Cancer  cells  are 
more  readily  destroyed  by  heat  than  healthy  tissue  cells, 
so  that  heat,  by  a  sort  of  slow  cooking,  is  now  used  in  the 
treatment  of  cancer  not  curable  by  the  knife.  By  this 
means  the  cancer  growth  may  be  arrested  even  if  a  per- 
manent cure  is  not  obtained.  An  electrically  heated  in- 
strument is  used,  with  the  patient  under  ether. 

Immunity  to  Cancer. — Gaylord  found  that  there  is  im- 
munity to  cancer.  That  mice  sometimes  spontaneously 
recover  from  inoculated  cancer;  that  these  cannot  again 
be  given  cancer;  and  that  their  blood  confers  slight  curative 
and  immune  effects  when  it  is  injected  into  animals  suf- 
fering from  cancer. 

There  have  been  some  recoveries  from  malignant  tumors 
in  man  caused  by  the  injection  of  cancer  cells  from  other 
human  patients  or  animals  in  the  same  way  that  we  cure 
infections  by  the  use  of  vaccines  composed  of  the  dead 
germs  causing  infections.  One  object  of  operating  in  the 
early  stage  of  cancer  is  that  then  the  patient's  immunity  is 
strongest.  In  the  late  stages  of  cancer  operation  may  lead 
to  rapid  recurrence  and  death,  as  it  seems  to  aggravate 
the  disease  in  the  absence  of  immunity.  In  cases  where 
the  cancer  is  of  slow  growth  there  is  much  natural  im- 
munity. 

Some  persons  and  families  appear  to  naturally  possess 
some  immunity  to  the  growth  of  cancer,  and  the  opposite 
tendency  may  explain  an  hereditary  susceptibility  to 
cancer  (much  questioned).  Dr.  Slye  has  recently  been 
able  to  breed  families  of  mice  in  which  cancer  occurred  in 


THE  PREVENTION  OF  CANCER  177 

most  of  the  adult  individuals.  This  is  either  due  to  in- 
herited lessened  immunity  to  cancer  or  to  increased  sus- 
ceptibility to  the  effects  of  irritation  or  injuries  to  the 
tissues.  There  is  no  reason  why  these  facts  cannot  be 
applied  to  the  human  being,  and  why  we  are  not  justified  in 
saying  that  cancer  may  be  inherited,  meaning,  as  in  the  case 
of  consumption,  that  the  tendency  is  inherited.  Editor- 
ially, the  Journal  of  the  American  Medical  Association 
(April  17,  1915)  regards  Dr.  Slye's  work  as  "one  of  the 
great  contributions  to  our  knowledge  of  cancer."  Dr. 
Slye  draws  two  practical  deductions:  (1)  The  elimination 
of  sources  of  irritation  of  the  tissues  in  persons  of  high 
cancer  ancestry;  and  (2)  that  the  control  of  marriage,  so 
that  cancer  may  not  be  potential  on  both  sides,  ought  to 
decrease  the  frequency  of  human  cancer  to  a  considerable 
degree.  It  has  been  found  that  after  .great  improvement 
from  one  or  two  treatments  of  cancer  with  x-ray  or  radium, 
the  growth  may  suddenly  become  much  worse  and  may 
spread  to  various  parts  of  the  body.  It  is  known  that  the 
power  of  immunity  against  the  growth  of  germs  and  cancer 
in  the  body  resides  in  the  lymphatic  system  (and  in 
the  bone-marrow  and  spleen),  and  that  this  system  is 
weakened  by  overuse  of  either  radium  or  x-ray,  hence  the 
need  of  the  greatest  care  and  experience  in  their  use. 

Cancer  Heredity. — The  hereditary  tendency  to  cancer 
is  doubted  by  leading  medical  authorities.  Dr.  William 
Mayo  affirms  that  he  knows  "no  evidence  that  would  lead 
to  this  belief" — i.  e.,  that  cancer  is  hereditary.  He  says 
the  tenet  that  some  families  have  tissues  which  on  chronic 
irritation  are  more  apt  to  develop  cancer  is  purely  problem- 
atic, and  also  notes  the  fact  that  the  occurrence  of  cancer  in 
several  members  of  a  family  is  not  strange  considering  its 
frequency.  He  quotes  the  enormous  statistics  of  Hoffman, 
statistician  of  the  Prudential  Insurance  Co.  of  America, 
12 


178  THE    PREVENTION   OF   DISEASE 

who  finds  not  the  slightest  evidence  "to  warrant  the  belief 
that  cancer  is  in  any  sense  hereditary." 

Taylor  summarizes  the  influence  of  heredity  in  cancer  as 
follows:  (1)  That  in  most  instances  heredity  exerts  no 
influence  in  cancer.  (2)  That  there  may  possibly  be  an 
exception  in  some  families.  (3)  That  some  precancerous 
conditions,  as  warts  and  birthmarks,  may  be  hereditary. 
The  most  striking  example  of  a  "cancer  family"  is  that  of 
Napoleon.  He  himself,  his  father,  two  sisters,  and  one 
brother  died  of  cancer. 

Cancer  heredity  is,  then,  doubtful  and  is  not  by  any 
means  an  ascertained  fact. 

Cancer  is  not  contagious.  Among  the  thousands  of 
cancers  operated  upon  daily  throughout  the  world  not  an 
instance  has  occurred  of  cancer  following  from  the  many 
accidental  cuts  and  pricks  sustained  by  surgeons  in  their 
work.  Other  infections  are  frequently  transmitted  in  this 
way.  Contact  of  husband  and  wife,  even  when  the  sexual 
organs  are  involved  by  cancer,  does  not  produce  cancer  in 
the  healthy  party. 

When  cancer  does  occur  in  husband  and  wife,  as  is  not 
uncommon,  it  is  only  coincidence,  such  as  would  be  ex- 
pected from  the  frequency  of  the  disease. 

To  indicate  the  enormous  extent  of  malignant  disease 
in  this  country  the  statistics  show  that  there  are  80,000 
deaths  from  cancer  in  the  United  States  annually,  includ- 
ing 25,000  deaths  from  cancer  of  the  stomach  and  18,000 
deaths  from  cancer  of  the  breast.  Also  that  the  rate  of 
mortality  from  cancer  is  increasing  2.5  per  cent,  per 
annum  (Hoffman). 

But  if  one  heeds  the  preliminary  stage  of  cancer,  which 
we  have  endeavored  to  impress  upon  the  reader  in  this 
chapter,  the  predisposing  causes  of  irritation  may  be 
removed  in  most  cases  before  cancer  results. 


THE  PREVENTION  OF  CANCER  179 

Even  when  the  patient  goes  to  the  surgeon  for  the  first 
time  in  the  early  period  of  genuine  cancer  the  curative  re- 
sults of  operation  are  wonderfully  better  than  those  ordi- 
narily obtained  in  cancer  in  the  various  stages  in  which  it 
is  treated  today.  Thus,  Dr.  Bloodgood,  the  distinguished 
surgeon  of  Johns  Hopkins,  and  the  leading  authority  on 
cancer  in  this  country,  offers  the  following  encouraging 
statement:  "From  what  we  know  of  the  early  signs  of 
cancer  and  the  local  growth  in  the  early  stages  of  cancer,  or 
what  precedes  cancer,  we  should  draw  the  greatest  en- 
couragement as  to  the  probability  of  the  percentage  of 
cures  possible  in  these  early  stages  by  good  surgery.  In  the 
breast  it  should  be  at  its  worst  86  per  cent.,  in  local  cancers 
of  the  skin  over  98  per  cent.,  in  the  lip  and  tongue  over  90 
per  cent.,  in  the  bone  over  75  per  cent.  With  the  ac- 
cumulating experience  of  each  succeeding  year  with  such 
early  cases,  the  percentage  of  cures  increases." 


CHAPTER  IX 

THE    PREVENTION    OF    SEXUAL  DISEASES  AND 
SEXUAL   HYGIENE 

INTRODUCTORY  NOTE 

IN  the  realm  of  preventive  medicine  no  more  vital  subject  can 
be  considered  than  that  which  stands  at  the  head  of  this  chapter. 
It  is  vital  partly  because  of  its  fundamental  relation  to  human 
society  and  race  betterment,  and  partly  because  until  recently  the 
whole  discussion  of  reproduction  and  the  sex  life  has  been  distorted 
by  misconceptions,  befogged  by  ignorance,  and  veiled  by  mysticism. 

The  medical  profession  will  welcome  the  author's  scientific  and 
conservative  presentation  of  this  subject  as  representing  a  message 
from  their  profession  to  the  public. 

The  laity  will  welcome  the  chapter  as  presenting  much  desired 
and  highly  prized  information  expressed  in  clear  and  concise  lan- 
guage, authoritative  and  reliable. 

The  author  is  especially  to  be  commended  for  the  stress  which 
he  lays  on  the  care  and  instruction  of  children  by  their  parents, 
with  a  view  of  controlling  physical  conditions  and  of  implanting 
'at  an  early  age  wholesome  ideas  and  high  ideals. 

WINFIELD  SCOTT  HALL. 

This  is  a  tremendous  subject,  but  the  discussion  herein 
will  be  chiefly  confined  to  protection  of  the  individual  rather 
than  the  public.  There  are  but  two  important  sexual 
diseases — gonorrhea  and  syphilis.  The  prevalence  of 
these  diseases  is  much  greater  than  most  persons  realize. 
Authorities  have  estimated  that  8  out  of  every  10  men  in 
New  York  have  had  gonorrhea,  and  that  3  out  of  every 
5  married  women  have  acquired  the  disease  in  some  de- 
gree in  consequence.  It  is  also  calculated  that  75  per  cent. 

180 


THE    PREVENTION    OF    SEXUAL    DISEASES  181 

of  all  operations  on  the  sexual  organs  of  women,  and  60 
per  cent,  of  the  work  done  by  specialists  in  women's  dis- 
eases, and  80  per  cent,  of  the  deaths  of  women  from  inflam- 
mation of  the  sexual  organs,  result  from  gonorrhea.  A 
large  part  of  sterility  in  both  men  and  women  (estimated  at 
50  per  cent.)  is  caused  by  gonorrhea.  Ten  per  cent,  of  all 
blindness  and  70  to  80  per  cent,  of  blindness  in  the  newborn 
are  attributable  to  gonorrhea. 

Gonorrhea  is  almost  always  contracted  by  sexual  inter- 
course with  a  victim  of  the  disease,  and  five  to  six  days 
must  intervene  (more  rarely  three  to  seven  days)  before  the 
first  symptoms  arise.  These  usually  consist  in  frequent 
and  painful  urination,  accompanied  by  a  whitish  discharge 
from  the  urinary  passage  which  causes  a  cloudiness  of  the 
urine  first  passed. 

The  disease  may  run  a  few  weeks  with  complete  recovery 
or  may  become  chronic  and  last  for  months,  or,  rarely,  for 
years,  during  which  time  the  patient  may  be  capable  of 
communicating  it  by  sexual  intercourse.  The  inflamma- 
tion frequently  invades  various  parts  of  the  sexual  and 
urinary  tracts  of  the  male  and  female,  but  is  not  by  any 
means  confined  to  these  organs. 

Gonorrhea  may  produce  general  blood-poisoning 
through  the  presence  of  the  special  germs  in  the  blood,  and 
these  may  also  attack  the  heart  or  joints,  with  the  most 
serious  results.  So-called  gonorrheal  rheumatism  is 
a  very  frequent  complication,  and  there  are  many  other 
sequels  of  the  disease.  Husbands  who  have  had  attacks 
of  gonorrhea  may  infect  their  wives,  and  if  the  latter  be- 
come mothers,  they  may  transmit  the  disease  to  the  eyes  of 
their  newborn  infants  during  the  process  of  birth.  This  is 
due  to  direct  -contact  of  the  baby's  eyes  with  germs  of 
gonorrhea  in  the  birth-passages  of  the  mother,  and  if  this 
does  not  happen,  there  is  no  other  acquired  or  inherited 


182  THE    PREVENTION   OF   DISEASE 

taint  in  the  offspring  from  the  disease  in  the  parents. 
Gonorrhea  in  either  sex  may  lead  to  death  years  after  its 
apparent  cure.  Thus,  a  male  patient  of  the  author's  has 
recently  died  from  the  effects  of  a  total  obstruction  of  the 
urinary  passage  (a  stricture)  caused  by  gonorrhea  acquired 
some  forty  years  previous.  The  consequent  retention  of 
urine  led  to  a  general  poisoning  (uremia)  of  the  whole  sys- 
tem. 

Syphilis,  while  usually  contracted  by  sexual  intercourse, 
is  sometimes  acquired  in  other  ways,  as  by  means  of 
drinking  cups,  towels,  eating  utensils,  brushes,  combs, 
barbers'  and  surgeons'  instruments,  kissing,  etc.  Syphilis 
germs  live  only  five  or  six  hours  outside  the  body.  The 
disease  is  most  often  acquired  between  the  ages  of  eighteen 
and  twenty-six.  Moist  lesions  in  the  mouth  and  sexual 
organs  are  the  only  means  of  transmission  of  syphilis. 
The  disease  begins  on  an  average  in  from  twenty  to  thirty 
days  after  exposure,  more  rarely  from  two  weeks  to  three 
months.  A  sore  then  appears  on  the  site  of  inoculation,  as 
on  the  private  parts,  lips,  etc.,  with  enlargement  of  glands 
in  the  neighborhood,  as  in  the  groins  when  the  sexual  organs 
are  involved.  After  six  weeks  the  so-called  secondary  stage 
appears,  with  fever,  sore  throat,  a  general  rash,  headache, 
and  pains  in  various  parts  of  the  body.  Falling  of  the  hair 
and  white  patches  in  the  throat  and  mouth  are  often  ob- 
served. This  stage  may  last  indefinitely  or  may  appear 
intermittently  for  years. 

The  secondary  stage  may  never  be  noticed  by  the 
patient,  or  complete  apparent  recovery  may  ensue,  or  the 
secondary  stage  may  glide  imperceptibly  into  the  third  or 
tertiary  stage.  There  is  no  regular  time  for  its  incidence. 
In  this  there  may  be  destructive  changes  in  any  organ  in 
the  body  or  upon  any  part  of  the  skin  surface.  Finally, 
there  is  a  fourth  stage  which  frequently  occurs  one  or  two 


THE    PREVENTION    OF    SEXUAL    DISEASES  183 

decades  after  apparent  complete  recovery  from  syphilis 
(not  less  than  eight  years),  and  its  commonest  manifesta- 
tion takes  the  form  of  either  locomotor  ataxia  (syphilis  of 
the  spinal  cord)  or  general  paresis  (syphilis  of  the  brain). 
Medically  well-treated  men  leading  a  temperate  life  are 
less  susceptible  to  paresis  and  locomotor  ataxia,  which 
occurred  in  about  1  per  cent,  of  1016  syphilitics  (White). 
Church  reports  (1916)  that  among  4000  Austrian  officers, 
examined  twenty-two  years  after  they  had  acquired 
syphilis,  some  1.5  per  cent,  had  developed  locomotor 
ataxia  and  4.6  per  cent,  had  developed  paresis.  He  be- 
lieves that  in  syphilitics  who  develop  paresis  or  locomotor 
ataxia  the  syphilitic  germ  has  become  so  modified  in  the 
body  that  it  acquires  a  special  affinity  for  the  nervous 
system — as  we  have  seen  is  the  case  in  respect  to  germs 
(streptococci)  which  enter  the  blood  from  diseased 
tonsils.  Syphilis  is  usually  not  communicable  for 
more  than  three  or  four  years  after  the  beginning  of 
the  disease.  Syphilis  is  transmitted  from  mother  to 
offspring.  In  fact,  it  is  the  only  disease  known  to  be 
so  transmitted  in  full  virulence,  although  it  is  not  prob- 
ably inherited  by  the  third  generation.  Syphilis  is 
said  to  be  the  cause  of  40  per  cent,  of  miscarriages  and  of 
many  still-births,  while  60  per  cent,  of  the  living  children 
die  at  an  early  age.  When  they  live  they  are  usually 
stunted  and  defective.  The  mortality,  as  a  whole,  in 
hereditary  syphilis  is  about  75  per  cent.  It  appears  more 
often  three  to  four  weeks  after  birth,  and  very  rarely  later 
than  six  months,  but  cases  as  late  as  the  twentieth  year  are 
recorded.  Children  are  often  born  absolutely  healthy  of 
syphilitic  parents.  The  disease  is  always  acquired  from 
the  mother,  never  from  the  father.  After  five  years  has 
elapsed  since  the  mother  has  acquired  syphilis  there  is 
little  danger  of  its  being  communicated  to  her  offspring,  but 


184  THE    PREVENTION   OF   DISEASE 

during  relapses  this  may  occur  for  eight  or  ten  years. 
In  such  a  case  she  may  have  healthy  alternating  with 
syphilitic  children.  If  a  pregnant  woman  has  active 
syphilis  and  is  treated  vigorously  early  in  the  disease,  es- 
pecially if  the  infection  occurs  after  the  seventh  month  of 
pregnancy,  the  chances  of  the  child  being  healthy  are 
much  greater.  The  mothers  of  syphilitic  children  fre- 
quently appear  perfectly  healthy  because  syphilis  is  often 
mild  in  women,  and  antibodies  are  formed  in  the  infected 
child  in  the  mother's  womb  which  protect  the  mother. 
Syphilis  has  been  a  disease  often  impossible  of  diagnosis 
because  it  remains  latent  for  years  in  persons  of  apparent 
robust  health,  only  to  break  out  anew  without  sign  or 
warning.  The  modern  tests  for  syphilis  (Wassermann  and 
Noguchi)  are  very  accurate,  but  until  recently  its  incidence 
has  been  mere  guesswork.  Its  prevalence  is,  indeed,  fearful 
to  contemplate.  Recent  results,  obtained  by  examination 
of  the  blood  by  means  of  the  Wassermann  test,  are  as  fol- 
lows :  In  1 1 1  children  in  a  Boston  hospital  (Lucas)  and  in 
102  children  in  a  Chicago  hospital  (Churchill)  one-third 
were  found  to  be  syphilitic.  Among  100  obstetric  patients 
in  an  Australian  hospital  (Piper)  1  in  6  patients  was  found 
to  be  infected  with  syphilis,  both  by  the  test  and  in  most 
cases  by  other  evidences  of  the  disease.  Browning  has 
recently  found  that  every  one  of  104  prostitutes  and  all  of 
109  tramps  were  suffering  from  syphilis. 

In  picked  men  (at  the  age  when  the  disease  is,  however, 
most  likely  to  be  taken)  the  prevalence  of  syphilis  is  much 
lower.  In  the  United  States  Army  the  rate  has  varied  in 
different  commands  from  2  to  10  per  cent.,  but  in  the  entire 
army  Nichols  affirms  that  syphilis  exists  to  the  extent  of 
over  5  per  cent.,  or  one  case  in  every  20  men.  Vedder1 

1  Prevalence  of  Syphilis  in  the  Army,  Surg.-Gen.  Bull.  No.  8, 
June,  1915. 


THE    PREVENTION    OF    SEXUAL    DISEASES  185 

however,  found  that  syphilis  was  prevalent  to  the  extent 
of  about  17  per  cent,  in  picked  recruits  for  the  army, 
after  83  per  cent,  of  the  number  applying  had  been  re- 
jected for  various  reasons,  including  a  recent  history  of 
syphilis.  Syphilis  shortens  life  about  four  to  five  years  on 
the  average;  in  25,000  insurance  risks  life  was  shortened 
five  and  one-half  years.  Syphilis  is  five  times  more 
common  in  men  than  women.  It  is  prevalent  to  the 
extent  of  about  10  per  cent,  in  men  in  foreign  cities 
and  in  from  5  to  10  per  cent,  in  American  cities.  There 
are  1,200,000  adult  syphilitics  in  the  United  States 
(Pusey).  The  "golden  period"  for  the  treatment  of 
syphilis  is  during  the  few  weeks  after  the  appearance 
of  the  sore  on  the  sexual  organs  and  before  the  begin- 
ning of  the  secondary  symptoms,  and  before  the  germs 
have  become  buried  in  the  tissues  all  over  the  sys- 
tem. With  modern  treatment  the  disease  may  be  wholly 
and  permanently  cured  by  killing  every  syphilitic  germ  in 
the  body  within  a  few  weeks  at  this  period  in  place  of  re- 
quiring several  years  by  the  older  methods. 

In  the  tertiary  period  syphilis  can  never  be  cured,  in  the 
sense  of  killing  all  the  syphilitic  germs  in  the  body.  The 
symptoms  may  often  be  wholly  relieved,  but  the  germs  are 
too  deeply  embedded  in  the  tissues  to  be  reached  by  drugs 
circulating  in  the  blood. 

Proper  treatment  in  the  early  secondary  stage  will 
result  in  99  per  cent,  of  permanent  cures.  By  the  older 
methods  about  90  per  cent,  of  cases  of  syphilis  were  cured 
in  dispensary  practice  and  97  per  cent,  in  the  best  private 
practice,  the  rest  going  on  into  the  tertiary  stage. 

Prevention  of  Sexual  Diseases. — The  vast  amount  of 
controversy  concerning  the  pros  and  cons  of  the  segrega- 
tion, legalization,  and  medical  supervision  of  prostitutes 
has  resulted  in  a  consensus  of  opinion  of  authorities  opposed 


186  THE    PREVENTION    OF   DISEASE 

to  this  as  a  means  of  preventing  immorality,  sexual  disease, 
and  crime. 

Our  task  is  to  consider  the  means  of  preventing  sexual 
disease  in  the  individual.  I  believe  that  the  problem  is 
largely  a  matter  of  proper  training,  education,  right  living, 
and  thinking;  that  the  means  employed  to  prevent  sexual 
disease  are  identical  with  those  most  beneficial  in  promot- 
ing the  general  health  of  body  and  mind  in  the  individual. 
It  is  folly  to  ignore  the  fact  that  the  sexual  desires  are  the 
most  powerful  of  any  in  the  world.  Self-control  is  neces- 
sary to  combat  them,  and  for  this  purpose  both  body  and 
mind  must  be  at  their  highest  point  of  health.  On  the 
other  hand,  it  is  right  to  pray,  "Lead  us  not  into  tempta- 
tion but  deliver  us  from  evil."  This  means  the  avoidance 
of  all  agencies  which  both  improperly  stimulate  the  sexual 
desires  and  weaken  the  will.  It  also  means  the  acquisition 
of  habits  which  strengthen  the  body  and  will  and  divert 
the  interests  and  activities  to  other  and  healthier  pursuits. 
The  reasons  for  refraining  from  immoral  practices  are  too 
self-evident  to  need  more  than  a  brief  reference  to  them. 
Morals  are  synonymous  with  customs,  and  customs  are 
usages  found  most  beneficial  for  the  individual  and  race. 
Immorality  then  leads  to  shame  and  deception  consequent 
upon  consorting  with  immoral  women.  It  involves  the 
chance  of  causing  illegitimate  pregnancy  in  the  woman  and 
the  danger  of  acquiring  one  or  both  of  the  dreaded  sexual 
diseases.  It  is  the  means  of  degrading  a  woman  who  might 
be  a  wife.  It  is  likely  to  lead  to  postponement  of  lawful 
marriage  and  to  be  a  source  of  lasting  regret  after  marriage 
to  a  chaste  partner.  It  lowers  the  whole  moral  tone 
through  association  with  depravity  and  the  attendant 
vices  of  vulgarity,  profanity,  and  the  use  of  alcohol,  cocain, 
morphin,  etc. 

While  escaping  temptation  is  not  so  glorious  or  helpful 


THE    PREVENTION    OF    SEXUAL    DISEASES  187 

as  overcoming  it,  yet  there  is  sure  to  be  enough  in  store. 
A  healthy  existence  with  plenty  of  outdoor  sport  and 
exercise  with  companions  of  the  same  sex  conduces  to 
normal  sexual  life.  Co-education  of  youth  in  high  schools 
of  both  sexes  is  to  be  condemned  as  favoring  sexual  evils, 
and  teachers  as  well  as  doctors  will  almost  universally 
endorse  this  opinion.  The  fashion  of  allowing  great  free- 
dom of  intercourse  between  the  youth  of  both  sexes  is,  in 
the  mind  of  the  author,  wholly  bad.  One  sees  boys  and 
girls  sprawling  about  together  in  hammocks  and  in  partial 
undress  on  beaches  without  let  or  hindrance  from  parents 
of  the  highest  social  standing.  Sexual  desire  is  one  of  the 
strongest,  if  not  the  strongest,  emotion  which  actuates  the 
human  being,  and  is  beyond  the  control  of  society,  however 
much  people  may  prate.  Close  intimacy  between  the  op- 
posite sexes  should  not  be  tolerated  before  the  beginning 
of  adult  life.  It  is  well  known  by  the  informed  that  the 
sexual  act,  from  a  physiologic  standpoint,  strictly  begins 
with  the  first  thought,  word,  look,  or  touch  relating  to  a 
desired  one.  And  while  the  persons  concerned  may  be 
wholly  innocent  or,  rather,  ignorant,  "yet  very  easily  may 
stimulation  pass  from  one  state  to  the  next,  the  next,  and 
the  next,  until  the  great  sexual  act  is  complete,  and  a  babe 
lies  nestled  at  its  mother's  breast."  In  this,  as  in  many 
other  matters,  it  is  well  to  regard  the  poet's  warning,  "Oh, 
small  beginnings  ye  are  great,"  and  avoid  them.  This, 
again,  means  the  avoidance  of  prurient  books  and  plays 
and,  above  all  else,  bad  companions.  Hard  work  and 
play  are  essential  to  the  healthy  body.  Idleness  here,  as 
always,  is  the  devil's  most  effective  tool. 

Constant  association  with  the  opposite  sex,  especially 
among  engaged  persons  to  whom  custom  allows  unusual 
intimacy  and  caresses,  often  results  in  great  physical  injury 
when  continued  for  a  long  time.  This  follows  because  con- 


188  THE    PREVENTION   OP   DISEASE 

tinual  stimulation  of  the  sexual  organs,  without  nature's 
mode  of  relief  in  sexual  intercourse  permitted  by  marriage, 
causes  local  congestion  and  inflammation  of  the  sexual 
organs  in  both  sexes.  Distressing  symptoms  arise,  and  the 
normal  functions  are  enfeebled  so  that  the  sufferer  may 
become  unfitted  for  marriage  when  the  time  comes  for  it  to 
occur.  Moreover,  the  frequent  sexual  excitement  en- 
gendered by  such  unnatural  intimacy  without  proper 
physiologic  relief  produces  a  state  of  nervous  exhaustion 
or  prostration  with  its  host  of  accompanying  evils,  and  the 
afflicted  person  is  wholly  unfitted  for  the  joys  or  duties  of 
life  and  becomes  an  abomination  to  himself  (or  herself) 
and  friends  alike.  Short  engagements  and  early  marriages 
are  desirable  (the  latter  especially  as  preventing  sexual 
disease)  when  they  may  take  place  without  privation. 
Long  engagements  should  be  shunned  unless  the  parties  to 
the  contract  are  separated  by  distance.  The  present  social 
state  of  the  world  does  not  favor  early  marriages  because 
the  position  demanded  by  society  may  not  be  attained 
without  a  long  course  of  training  or  years  spent  in  trade. 

A  recent  writer  has  marshalled  statistics  to  prove  that 
the  partners  of  early  marriages  in  the  middle  classes  have 
a  much  higher  death-rate  than  their  friends  who  marry 
later,  owing  to  the  excessive  struggle  required  to  retain 
their  place  among  social  equals. 

The  use  of  alcohol  among  young  men  is  especially  con- 
ducive to  sexual  immorality,  since  it  not  only  excites  the 
sexual  desire,  but  has  an  equally  paralyzing  influence  over 
the  will  power.  This  is  universally  recognized — the 
shedding  of  modesty,  reserve,  and  self-control  under  the 
action  of  alcohol — as  evidenced  by  the  old  saying,  "in  vino 
veritas." 

Among  all  other  influences  alcohol  and  persuasively  bad 
companions  head  the  list  in  favoring  sexual  immorality. 


THE    PREVENTION    OF    SEXUAL    DISEASES  189 

The  sexual  organs  are  stimulated  by  highly  spiced  or 
peppered  food,  by  an  overabundance  of  meat  or  eggs,  and 
sleeping  on  soft  beds  with  an  overwarm  covering. 

Conversely,  the  daily  morning  cold  bath  and  the  use  of 
a  moderately  hard  bed  with  light  coverings  are  to  be  recom- 
mended. The  first  and  chief  aid  to  the  young  man  should 
be  the  thought  that  he  will  marry,  and  that  the  sort  of 
woman  he  wants  will  demand  that  he  be  as  chaste  as  her- 
self. Keeping  this  always  before  him — living  the  proper 
life,  full  of  work  and  play,  and  knowing  the  danger  to 
morals  and  health  from  being  unchaste — he  will  serenely 
pursue  his  way,  exerting  self-control  to  the  utmost  when 
temptation  arises. 

Supposing  a  young  man  has  already  fallen  from  grace 
owing  to  infection  with  one  of  the  sexual  diseases,  is  it  safe 
for  him  to  marry  without  endangering  the  health  of  wife 
and  possible  offspring?  In  such  a  case  no  man  should 
marry  without  a  careful  medical  examination  by  a  special- 
ist in  genito-urinary  diseases,  and  only  recently  (1913)  a 
similar  test  was  requested  by  statute  in  Wisconsin  and  has 
been  upheld  by  the  Supreme  Court  of  the  state  (1914). 
After  proper  treatment,  and  the  lapse  of  two  years  from 
the  appearance  of  the  last  manifestation  of  syphilis,  a 
man  may  safely  marry,  according  to  Osier.  This  advice 
should  also  include  several  negative  Wassermann  tests 
taken  at  intervals  during  the  first  three  years.  Hoffman's 
rule  is  often  followed  concerning  marriage  of  syphilitic 
men;  that  is,  if  men  have  been  thoroughly  treated,  and 
have  had  no  symptoms  for  two  years,  they  may  marry  from 
three  to  five  years  after  the  onset  of  syphilis.  The  Was- 
sermann test  is  unimportant  in  this  connection  after  five 
years,  for  of  a  large  number  of  men  having  healthy  chil- 
dren five  years  after  the  beginning  of  syphilis  50  per  cent, 
showed  a  positive  Wassermann  test.  Within  the  first  three 


190  THE   PREVENTION   OF   DISEASE 

years  a  positive  Wassermann  test  should  mean  postpone- 
ment of  marriage.  So  that  five  years  after  the  beginning 
of  syphilis,  in  a  man  who  has  been  well  treated  medically 
and  free  from  symptoms  for  two  years,  marriage  may  be 
sanctioned  despite  the  existence  of  a  positive  Wassermann 
test  (Pusey). 

In  the  case  of  a  person  who  has  had  gonorrhea  a  careful 
microscopic  examination  of  any  discharge  which  exists 
(or  may  be  made  to  appear  by  massage  of  the  deeper  parts 
of  the  urinary  tract,  and  the  drinking  of  a  considerable 
amount  of  beer)  may  be  necessary  to  determine  the 
presence  of  the  special  germ  and  the  danger  of  contagion. 
Then  the  new  test  (complement-fixation)  is  of  great  value 
in  discovering  chronic  and  apparently  cured  cases  of  gonor- 
rhea. By  proper  treatment  the  male  patient  can  usually 
be  permanently  cured  within  a  few  weeks  or  months. 

To  avoid  direct  exposure  to  possible  infection  with 
syphilis  one  should  refrain  from  use  of  a  common  towel, 
hair-brush,  comb,  soap,  drinking  cup,  and  barber's  imple- 
ments (more  particularly  the  razor).  During  the  past  few 
years  preventive  measures  have  been  used  in  the  treatment 
of  males  who  have  been  exposed  to  the  perils  of  sexual  in- 
tercourse in  order  to  avert  infection  with  either  gonorrhea 
or  syphilis.  Objection  may  be  raised  to  this  on  the  ground 
that  rendering  illegitimate  intercourse  free  from  nature's 
punishment  will  only  encourage  its  greater  prevalence. 
While  such  reasoning  may  to  some  extent  be  borne  out 
by  the  facts,  yet  the  risk  to  innocent  wives  and  babes  un- 
born and  to  other  sufferers  from  accidental  infection  is 
paramount  and  will  justify  all  such  measures  which  will 
reduce  the  prevalence  of  the  sexual  diseases.  In  the  case 
of  newborn  infants  it  is  the  rule  that  drops  of  a  2  per  cent, 
solution  of  silver  nitrate  or  a  20  per  cent,  solution  of  argy- 
rol  should  always  be  instilled  into  their  eyes  a  few  moments 


THE    PREVENTION    OF    SEXUAL    DISEASES  191 

after  birth,  to  prevent  the  possibility  of  gonorrheal  infec- 
tion and  consequent  loss  of  sight. 

The  same  drugs  will  in  most  cases  prevent  the  disease  in 
men  if  dropped  into  the  urinary  passage  within  a  few  hours 
after  sexual  intercourse. 

Metchnikoff,  in  experiments  on  monkeys,  found  that 
protection  against  infection  with  syphilis  could  be  secured 
in  most  cases  by  the  application  of  ointment  containing 
30  per  cent,  of  calomel.  A  young  medical  student,  Paul 
Maisonneuve,  allowed  himself  to  be  inoculated  from  two 
virulently  infected  patients,  and  then  calomel  ointment 
was  applied  one  hour  later,  with  no  development  of 
syphilis,  while  a  monkey  succumbed  from  the  same  infec- 
tion without  treatment.  Treatment  must  be  applied 
within  eighteen  hours,  and  the  sooner  the  better.  In  the 
United  States  Army  and  Navy  these  methods  have  been 
enforced  during  the  past  few  years  with  most  successful 
results.  The  principle  is  laid  down  that  no  man  has  a 
right  to  deprive  the  government  of  his  services  and  to 
become  a  burden  besides  through  sickness.  Therefore 
every  exposed  soldier  or  sailor  returning  to  garrison  or  ship 
is  required  to  report  for  preventive  treatment. 

This  consists,  first,  in  thorough  washing  of  the  sexual 
organs  with  soap  and  water,  dropping  into  the  urinary  pass- 
age a  medicine-dropperful  of  a  freshly  prepared  20  per  cent, 
solution  of  argyrol,  and  squeezing  the  end  of  the  passage  to 
keep  the  solution  in  for  five  minutes;  and,  finally,  rubbing 
a  salve,  composed  of  benzoinated  lard  containing  30  per 
cent,  of  calomel,  thoroughly  over  the  whole  surface  of  the 
sexual  organs.  Neither  of  these  drugs  produce  any  dis- 
comfort. As  argyrol  solution  does  not  keep,  it  may  be 
freshly  made  by  dissolving  12  grains  of  argyrol  (which 
keeps  indefinitely  in  powder  in  a  stoppered  bottle)  in  a 
teaspoonful  of  cold  water.  In  the  United  States  Army  and 


192  THE   PREVENTION   OF   DISEASE 

Navy  the  man  who  develops  sexual  disease  without  re- 
porting his  exposure  and  receiving  preventive  treatment  is 
punished.  The  results  of  this  treatment  are  as  follows: 
Major  Howard  reports  but  1  case  of  syphilis  in  3800  ex- 
posures, and  that  the  yearly  ratio  of  sexual  diseases  had 
been  cut  from  227  to  18  per  1000.  That  the  prevent- 
ive measures  are  not  generally  so  successful  on  the  aver- 
age in  the  whole  army  (in  1913)  is  shown  by  the  report 
that  the  rate  of  sexual  diseases  per  1000  men  has  fallen 
from  115  to  85  (Nixon).  This  moderate  reduction  is  prob- 
ably due  in  great  part  to  carelessness  in  the  use  of  the  pre- 
ventive measures.  But  it  must  be  borne  in  mind  that  no 
preventive  measures  will  certainly  preclude  the  possibility 
of  an  attack  of  one  or  both  of  the  sexual  diseases  after 
exposure  through  sexual  intercourse.  And,  as  has  been 
pointed  out,  there  are  numerous  other  reasons,  besides  the 
danger  of  infection  with  venereal  diseases,  why  a  self- 
respecting  person  should  avoid  the  moral  and  social 
risks  of  illegitimate  sexual  intercourse.  Moreover,  with- 
out personal  instruction  from  a  physician  in 'the  use  of 
the  drugs  described  for  the  prevention  of  sexual  diseases 
the  result  is  likely  to  be  a  failure.  Avoidance  of  exposure 
to  these  diseases  is  the  chief  essential  in  prevention  of 
the  diseases  themselves.  A  bachelor  may  refrain  from 
sexual  intercourse  indefinitely  without  harm,  providing 
he  does  not  subject  himself  to  agencies  which  frequently 
excite  the  sexual  desires.  If  the  sexual  organs  are  con- 
stantly stimulated  under  such  conditions  the  result  may 
be  as  disastrous  as  not  infrequently  occurs  in  engaged 
persons  noted  above. 

But  the  real  preventive  measures  against  sexual  disease 
should  be  beguft*by  the  parents  at  birth,  and  if  the  boy  is 
properly  taught  during  his  first  ten  years,  when  the  brain 
is  most  impressionable,  his  future  will  be  in  most  cases 


THE    PREVENTION    OF    SEXUAL    DISEASES  193 

secure.  If  the  mother  or  father  begin  during  the  first  few 
years  to  talk  naturally  about  the  sexual  organs,  as  one 
would  instruct  a  child  about  the  care  of  his  teeth  or  other 
part  of  the  body,  the  child  will  have  no  hesitancy  in  report- 
ing any  happenings  of  his  own  bearing  on  this  matter,  for 
there  will  always  be  older  and  vicious  boys,  girls,  or  adults 
who  will  try  to  lead  him  or  her  astray. 

Self-abuse. — The  chief  endeavor  in  young  children 
should  be  to  prevent  masturbation  or  self-abuse,  whereby 
the  sexual  organ  is  so  stimulated  by  rubbing  or  irritation 
that  the  child  experiences  the  same  sensations  and  excite- 
ment (orgasm)  which  occur  during  sexual  intercourse. 
Any  local  irritation  about  the  penis  in  the  male  will  cause 
the  child  to  handle  the  part,  and  so  he  will  be  more  likely 
to  acquire  the  bad  habit.  For  this  reason  circumcision  is 
advisable  in  the  male  in  preventing  the  retention  of  secre- 
tion and  urine  and  avoiding  consequent  irritation.  This 
operation  may  be  best  done  after  the  infant  is  two  or  three 
weeks  old  and  before  the  monthly  nurse  departs.  The 
writer  believes  in  circumcision  as  a  routine  practice  for 
every  male  child.  As  the  foreskin  is  somewhat  adherent  in 
infants,  many  trained  nurses  are  taught  to  force  it  back 
by  daily  attempts  at  withdrawal.  The  author  does  not 
believe  in  this  practice,  as  it  may  have  the  effect  of  arousing 
desire  for  stimulation  of  the  organ  even  at  this  early  age. 
Self -abuse  is  not  confined  to  children,  but  is  often  practised 
by  monkeys  and  other  male  animals.  It  is  not  nearly  so 
common  in  girls,  but  is,  on  the  other  hand,  not  rare  The 
more  exposed  organs  of  the  male  probably  favors  irritation. 
Babies  may  bring  the  sexual  crisis  or  orgasm  about  by  rub- 
bing the  thighs  together.  They  should  be  carefully 
watched  to  prevent  irritation  of  their  sexual  organs  by  any 
method,  and  should  be  punished  if  found  addicted  to  the 
habit.  As  soon  as  children  are  old  enough  they  should  be 

13 


194  THE   PREVENTION   OF   DISEASE 

told  that  handling,  rubbing,  or  irritating  their  sexual  organs 
is  bad  for  them.  They  should  also  be  warned  not  to  per- 
mit any  other  child  or  person  to  touch  their  sexual  organs 
and  to  report  any  occurrence  of  the  kind.  When  they  are 
eight  or  ten  years  old  boys  should  be  instructed  as  to  the 
harm  done  by  masturbation.  As  a  matter  of  fact,  in  the 
past  almost  all  boys  have  masturbated  for  a  longer  or 
shorter  time,  and  have  given  up  the  practice  from  some 
inherent  sense  of  decency  and  because  companions  have 
told  them  it  would  make  them  crazy.  With  the  prevailing 
custom  of  education  in  these  matters  the  habit  should  be- 
come infrequent.  The  harm  done  is  that  wrought  by 
frequent  stimulation  of  the  immature  nervous  system,  so 
this  is  the  most  important  part  of  the  body  to  suffer. 
Then  there  is  no  limit  to  the  frequency  of  the  practice, 
which  does  not  obtain  in  sexual  intercourse.  When  boys 
masturbate  after  reaching  the  age  of  puberty  (beginning 
at  some  period  between  twelve  and  seventeen  and  lasting 
two  years  or  so)  there  is  a  loss  of  the  fluid  (semen)  secreted 
from  this  time  on  by  the  testicles,  and  containing  the 
millions  of  microscopic  sperm  cells,  any  one  of  which  will 
produce  a  new  individual  when  it  comes  in  contact  with  the 
female  germ  cell,  egg,  or  ovum. 

We  may  summarize  the  evil  effects  of  self-abuse  as 
follows:  (1)  The  shock  to  the  nervous  system,  noted 
above.  (2)  The  loss  of  sperm  cells  representing  such 
tremendous  energy  and  incredible  potentiality.  (3)  Less- 
ened formation  and  absorption  into  the  blood  of  the  in- 
ternal secretion  of  the  testicle  which  determines  and  con- 
trols the  development  in  the  youth  of  the  sexual  attri- 
butes of  the  virile  adult  male  (Marshall). 

These  consist  in  tremendous  growth  of  the  long  bones, 
particularly  in  the  thighs,  which  give  height  to  the  frame; 
in  the  growth  of  the  sexual  organs,  and  also  in  the  appear- 


THE    PREVENTION    OF    SEXUAL    DISEASES  195 

ance  of  hair  on  these  parts  and  on  the  face;  in  the  change  of 
voice,  which  is  said  to  be  due  to  lengthening  of  the  vocal 
cords.  All  these  evidences  of  increased  nutrition  are  due 
in  great  part  to  the  activity  of  certain  glands  which  pour 
their  secretions  into  the  blood.  They  each  have  their 
function  to  perform,  and  if  one  produces  a  greater  or  less 
amount  of  secretion  than  normal  the  most  serious  results 
ensue.  Thus,  disturbances  of  the  secretion  of  the  small 
gland  at  the  base  of  the  brain  (pituitary)  may  either  be  the 
cause  of  such  growth  that  a  giant  is  produced  or,  on  the 
other  hand,  the  subject  may  become  very  fat  and  the 
sexual  organs  may  become  undeveloped.  Total  removal 
of  the  thyroid  gland  (in  the  region  of  the  Adam's  apple  in 
the  neck)  will  cause  an  individual  to  become  unrecogniz- 
able by  coarsening  of  the  features,  and  many  other  serious 
changes  occur.  Removal  of  the  testicles  and  ovaries 
produce  marked  alterations  in  the  body  and  character. 
So  it  is  wise  to  impress  upon  the  growing  youth  (Prof. 
Hall)  that  the  secretion  of  the  testicles  must  not  be  wasted, 
as  it  is  necessary  to  make  the  body  strong  and  athletic  and 
to  preserve  the  balance  essential  to  the  proper  functioning 
of  the  various  ductless  glands. 

While  excessive  masturbation  may  so  break  down  the 
general  health  as  to  lead  to  the  production  of  impotency, 
sterility,  and  even  idiocy  and  insanity,  these  are  very  rare 
occurrences,  and  it  is  really  the  case  that  idiocy  and  insan- 
ity are  more  frequently  responsible  for  the  lack  of  self- 
control  which  results  in  such  an  unnatural  habit.  When 
children  have  acquired  the  habit  they  are  apt  to  be  thin, 
nervous,  and  peevish,  and  at  a  later  period,  after  ten  or 
twelve,  the  subject  is  prone  to  lose  interest  in  play  and 
become  depressed  and  sit  by  himself  and  mope.  He  is 
sallow  and  loses  his  appetite.  Parents  should  be  on  the 
watch  for  such  signs  and  have  a  confidential  talk  with  the 


196  THE   PREVENTION   OF   DISEASE 

lad.  If  he  confesses  to  the  habit,  the  boy  should  be  en- 
couraged and  told  that  if  he  exerts  his  self-control  he  will 
soon  overcome  it  and  no  evil  effects  will  ensue. 

The  treatment  consists  in  not  allowing  children  to  sleep 
together  and  in  requiring  them  to  sleep  on  rather  hard  beds 
with  light  covering.  A  boy  who  has  contracted  the  habit 
should  riot  be  permitted  to  lie  in  bed  after  waking  nor  read 
in  bed  after  retiring.  He  should  take  a  cold  bath  in  the 
morning  and,  if  tempted  to  indulge,  should  bathe  the  sex- 
ual organs  in  cold  water.  Plain  diet,  without  an  excess  of 
meat  or  eggs,  and  an  outdoor  life  are  desirable.  Horse- 
back exercises  often  lead  to  stimulation  of  the  sexual  or- 
gans, however,  owing  to  friction  of  the  saddle. 

Improper  books,  shows,  and  companions  must  be 
avoided.  Circumcision  is  advisable.  But  the  instruction 
of  the  child  from  the  earliest  year  should  prevent  the  oc- 
currence of  self-abuse,  and  if  such  has  not  been  begun 
early,  then  it  is  much  more  difficult  to  talk  to  boys  about  the 
later  dangers.  At  the  age  of  puberty  (twelve  to  seventeen) 
the  boy  should  be  warned  by  his  father,  or  by  a  doctor, 
of  the  occurrence  of  spontaneous  discharge  of  semen  from 
the  penis  during  sleep.  These  so-called  "pollutions"  are 
normal  if  they  do  not  happen  more  than  once  or  twice  a 
week ;  when  occurring  three  times  or  more  a  doctor  should 
be  consulted. 

The  use  of  a  hard  bed,  light  covering,  cold  water  applied 
to  the  sexual  organs,  abstinence  from  alcohol,  tobacco,  and 
avoidance  of  such  books  and  plays,  or  intimacy  with  the 
opposite  sex,  as  might  excite  sexual  desires,  are  all  part  of 
the  treatment.  Sleeping  on  the  back  favors  loss  of  seminal 
fluid  at  night,  and  may  be  avoided  by  tying  a  towel  about 
the  waist  with  a  knot  in  the  back.  At  this  period,  also,  boys 
should  be  warned  against  the  perils  of  sexual  intercourse 
which  have  been  discussed  in  the  earlier  part  of  this  section. 


SEXUAL    HYGIENE    IN    MARRIAGE  197 

SEXUAL  HYGIENE  IN  MARRIAGE 

Both  man  and  maid  enter  into  wedlock  with  the  greatest 
ignorance  of  the  physiology  of  the  sexual  organs  in  most 
cases.  Custom  has  made  ignorance,  masquerading  as 
modesty,  seem  the  only  decent  course  in  this  matter,  but 
it  is  a  fatal  mistake,  as  the  experience  of  doctors  soon 
teaches  them.  Just  as  during  a  long  marriage  engagement 
stimulation  of  the  sexual  organs  without  physiologic  relief 
in  sexual  intercourse  leads  to  nervous  breakdown  and 
local  inflammations  of  the  sexual  organs,  so  do  unnatural 
practices  in  sexual  intercourse  during  married  life  produce 
equally  unfortunate  results. 

Both  the  man  and  the  woman  should  secure  medical 
advice  before  marriage  concerning  the  marital  sexual  rela- 
tions, or,  when  this  is  not  feasible,  a  book  of  this  kind  may 
serve  in  a  measure  as  a  poor  substitute. 

It  will,  at  any  rate,  suggest  the  importance  of  many 
matters  which  may  lead  to  the  seeking  of  professional  ad- 
vice in  difficulties.  The  woman  should  know  that  she  will 
be  subjected  to  sexual  intercourse  immediately  after 
marriage,  and  she  should  not  be  imbued  with  the  idea  that 
her  husband  is  unusually  sensual  or  brutal  in  expecting  this 
of  her.  On  the  other  hand,  the  man  should  understand 
that  as  the  first  impressions  of  fear  and  pain  may  render 
sexual  intercourse  unpleasant  to  his  wife  for  months  or 
years,  he  should  be  especially  considerate  in  this  respect 
in  the  beginning  of  their  sexual  relations.  Indeed,  in  some 
cases  it  may  be  wise  for  him  to  refrain  from  such  for  a  day 
or  so  until  mutual  love  and  desire  break  down  all  barriers. 
In  some  women  the  hymen,  or  membranous  fold  which 
partially  closes  the  front  passage,  offers  so  much  resistance 
that  it  may  be  badly  torn  and  give  rise  to  considerable 
bleeding  from  the  results  of  sexual  intercourse.  Gradual 


198  THE    PREVENTION   OF   DISEASE 

dilation  is  sometimes  done  by  physicians  before  marriage, 
but  is  rarely  necessary. 

Still  this  is  one  reason  why  a  professional  consultation 
may  not  be  amiss  in  the  case  of  the  woman  about  to  marry. 

The  wear  and  tear  of  preparation  for  marriage,  the 
achieving  of  the  trousseau,  together  with  that  of  the 
ceremony  itself  and  travel  afterward,  is  but  a  poor  begin- 
ning for  married  life.  If  to  offset  the  exhaustion  conse- 
quent to  these  doings  indulgence  in  wine  is  added  in  cele- 
brating the  event,  we  have  the  most  unfavorable  state 
for  the  conception  of  a  child.  The  honeymoon  should  be 
passed  in  a  quiet  country  place,  at  the  mountains,  seaside, 
or  on  the  water,  among  the  most  healthy  surroundings. 
Travel,  hotel  life,  and  sight-seeing  are  only  fit  for  the  un- 
commonly robust  at  such  a  time. 

The  frequency  of  sexual  intercourse  is  a  matter  of  im- 
portance. Persons  differ  in  their  sexual  power  as  much  as 
in  muscular  strength  or  in  any  other  physical  quality,  and 
it  is  not  any  more  possible  to  lay  down  exact  rules  than  it 
would  be  to  state  precisely  the  amount  of  food  required  by 
any  individual.  During  the  first  few  weeks  of  married  life 
it  is  too  much  to  expect  any  very  rigid  adherence  to  rules, 
but  later  the  axiom  laid  down  by  Luther  is  as  good  as  any 
we  know.  He  said,  "twice  a  week  we  need  not  fear." 
Repetition  of  the  act  during  the  night  or  day  is  inadvisable. 
The  use  of  alcohol  at  such  times  leads  to  subsequent  ex- 
haustion, and  endangers  the  health  of  a  child  conceived 
under  these  conditions,  whether  father  or  mother  be  the 
transgressor. 

Sexual  relations  are  forbidden  by  custom  during  men- 
struation, and  in  some  religions  severe  penalties,  even 
death,  are  attached  to  disobedience  of  this  command.  In 
animals  sexual  intercourse  is  only  practised  during  such 
periods  (rut,  heat),  and  the  sexual  desire  is  often  strongest 


SEXUAL    HYGIENE    IN    MARRIAGE  199 

during  the  latter  part  of  menstruation  in  women.  While 
abstinence  is  the  rule  from  a  sense  of  delicacy  and  esthetic 
considerations,  there  is  no  evidence  that  physical  harm 
to  man  or  woman  results  from  sexual  intercourse  during  the 
"unwell"  period.  Sexual  intercourse  is  permissible  dur- 
ing pregnancy  (unless  there  has  been  a  tendency  to  mis- 
carriages) except  in  the  last  month  or  two,  and  except 
during  six  weeks  after  childbirth  or  after  a  miscarriage. 

Since  the  nervous  system  of  the  woman  is  disturbed 
during  menstruation  and  the  pregnant  state  the  husband 
should  make  allowance  for  depression,  peevishness,  un- 
reason, and  irritability  at  these  times,  and  treat  his  wife 
with  unusual  gentleness  and  consideration  in  consequence. 
Excess  in  the  matter  of  sexual  intercourse  is  at  once  shown 
by  the  effect  upon  the  general  health.  Headache,  press- 
ure or  pain  in  the  back  of  the  neck,  exhaustion,  lack  of  in- 
terest and  energy,  with  mental  depression,  may  be  the 
immediate  result.  .  The  appetite  and  digestion  are  im- 
paired, and  there  may  be  pain  in  the  loins  and  increased 
susceptibility  to  " catching  cold."  In  women  there  may 
be  a  white  discharge  from  the  front  passage  or  vagina. 
The  cause  of  such  symptoms  should  readily  be  recognized 
and  corrected  at  the  earliest  moment.  Women  should 
not  feel  abashed  at  discovering  themselves  subjects  of 
sexual  passion,  when  happily  married,  although  their  up- 
bringing has  often  led  them  to  believe  such  feelings  im- 
modest and  unladylike.  This  is,  of  course,  all  bosh,  and  a 
happy  marriage  means  a  happy  union  of  the  soul,  mind, 
and  body. 

Overwork,  anxiety,  pre-occupation,  poor  health,  and 
unvaried  monotony  of  life  will  abolish,  to  a  considerable 
extent,  the  natural  sexual  desires.  Change  of  scene  and 
relaxation  will  often  restore  the  normal  sexual  functions. 
Absolute  personal  cleanliness  is  essential  in  both  partners, 


200  THE    PREVENTION    OF   DISEASE 

and  offense  to  the  senses  has  an  immediate  influence  in 
destroying  sexual  desire. 

We  hear  much  now-a-days  about  race  suicide.  This  is 
not,  of  course,  due  to  any  loss  of  vitality  in  the  race,  but  is 
caused  by  artificial  methods  for  the  prevention  of  preg- 
nancy. 

While  this  is  often  wholly  inexcusable,  the  condition  of 
the  woman  may  be  such  as  to  endanger  her  life  were  she  to 
become  pregnant,  and  too  frequent  pregnancies  are  ex- 
hausting and  inadvisable.  Financial  circumstances  and 
the  health  and  happiness  of  the  family  may  require  limita- 
tion of  offspring,  however.  The  reasons  for  and  the  desir- 
ability and  justification  of  pursuing  such  a  course  are 
strikingly  set  forth  in  a  recent  book.1  Almost  all  the  arti- 
ficial means  of  preventing  pregnancy  are  more  or  less  un- 
reliable or  injurious  to  the  health.  The  common  practice 
on  the  part  of  the  husband  of  withdrawing  before  final  com- 
pletion of  the  sexual  act,  so  as  to  avoid  conception,  is  quite 
likely  to  cause  a  breakdown  in  his  wife's  nervous  system. 
The  author  has  in  mind  the  case  of  a  fine,  healthy,  at- 
tractive young  woman  who  became  a  nervous  wreck  from 
this  means,  because  she  dreaded  a  second  child  after  a  hard 
and  painful  delivery  of  the  first  baby. 

The  setting  free  of  the  ovum  or  egg  from  the  woman's 
ovary  does  not  always  coincide  with  the  time  of  menstrua- 
tion. This  is  shown  by  the  fact  that  women  become  preg- 
nant when  they  have  not  been  unwell  for  months  pre- 
viously, as  while  nursing  a  baby  or,  very  rarely,  after  the 
change  of  life.  Then  the  spermatozoa,  or  germ  cells  of  the 
man,  may  remain  alive  in  the  tubes  of  the  woman  for  three 
weeks  after  sexual  intercourse. 

1  "Fewer  and  Better  Babies  or  Limitation  of  Offspring  by  Pre- 
vention of  Conception,"  W.  J.  Robinson,  M.  D.,  Critic  and  Guide  Co., 
New  York,  1915, 


SEXUAL    HYGIENE    IN    MARRIAGE  201 

So  that  it  will  be  seen  that  menstruation  is  not  the  time 
during  which  a  woman  is  most  likely  to  become  pregnant. 
The  flow  of  blood  will  tend  to  wash  out  the  male  germ  cells. 
There  is,  in  fact,  no  time  when  sexual  relations  are  free 
from  the  possibility  of  pregnancy,  either  before,  or  after, 
or  between  or  during  the  unwell  periods.  It  has,  how- 
ever, been  found  by  experience  that  conception  is  most  apt 
to  occur  within  the  first  eight  days  after  the  end  of  men- 
struation, and  is  least  likely  to  take  place  between  the 
fourteenth  and  twenty-first  day  after  menstruation.  To 
show  nature's  prodigality  in  the  way  of  propagation  possi- 
bilities it  has  been  calculated  that  a  man  is  capable  of 
producing  some  300,000,000,000  spermatozoa  during  his 
sexual  life,  while  a  young  woman  starts  out  with  30,000 
potential  eggs  in  her  ovaries.  When  the  health  of  the 
wife  demands  the  avoidance  of  pregnancy  a  doctor  should 
be  consulted  and  he  will  then  feel  justified  in  recommend- 
ing quite  certain  methods  for  its  prevention. 

While  a  woman  nurses  her  child  menstruation  usually 
ceases  and  conception  does  not  often  occur.  On  the  other 
hand,  menstruation  may  begin  almost  any  time  during  the 
milk-giving  period,  and  then  conception  is  as  likely  to  occur 
as  at  any  other  time.  Extraordinarily,  conception  may 
happen,  even  in  the  absence  of  menstruation,  while  the 
mother  is  nursing,  as  noted  above. 

Married  life  exerts  a  strong  influence  on  disease  and  lon- 
gevity. There  are  Swedish  statistics  which  show  that  there 
are  twice  as  many  single  men  who  die  at  the  age  of  forty  as 
married  men  at  the  same  age.  These  figures,  which  deal 
with  deaths  in  Sweden  between  1881  and  1890,  give  14.67 
deaths  of  single  men  at  forty  as  against  7.42  deaths  among 
married  men  at  forty  per  1000;  while  at  forty-five  there 
were  19.07  deaths  among  single  men,  as  compared  with 
9.22  deaths  among  married  men  per  1000.  Among  women 


202  THE   PREVENTION    OF   DISEASE 

the  saving  in  life  is  not  so  great,  on  account  of  the  dan- 
gers, cares,  work,  and  vicissitudes  of  married  life,  but 
there  is  a  considerable  advantage  in  favor  of  the  married. 
Using  the  same  statistics  as  above,  at  the  childbearing  age 
of  thirty  the  deaths  per  1000  among  married  women  are 
6.37,  and  among  single  women  6.42;  while  at  the  age  of 
fifty  the  number  of  deaths  in  married  women  per  1000  are 
but  8.99,  as  against  12.18  among  single  women.  The 
regularity  of  the  habits  of  the  married,  the  greater  freedom 
from  dissipation  among  married  men,  and  the  fact  that, 
as  a  class,  the  stronger  and  healthier  are  those  who  marry 
account  for  the  greater  longevity  of  wedded  persons. 

At  the  age  of  fifty  it  has  been  computed  that  the  married 
man  has  an  expectation  of  five  years  longer  life  than  the 
single  male,  while  the  married  woman  at  the  same  age  has 
an  expectation  of  one  year  longer  life  than  the  spinster  of 
the  same  age.  Many  of  the  accidents  incidental  to  the 
childbearing  period  can  be  prevented  by  modern  methods 
and  will  increase  the  longevity  of  the  married  woman  ac- 
cordingly. It  is  said,  on  good  authority,  that  the  preg- 
nant wife  is  less  subject  to  fatality  than  the  non-pregnant 
on  account  of  the  extra  care  given  her  at  this  time. 


CHAPTER  X 

THE    PREVENTION    OF    ACUTE    AND    CHRONIC 
RHEUMATISM  AND  ACUTE  TONSILLITIS 

WE  have  already  considered  in  another  place  the  far- 
reaching  and  damaging  effects  of  tonsillitis  and  other  local- 
ized infections  in  the  production  not  only  of  rheumatism, 
but  of  many  other  serious  disorders  (see  page  145). 

In  the  prevention  of  rheumatic  fever  and  various  forms 
of  so-called  rheumatism  we  find  the  tonsils  to  be  the  chief 
source  of  these  troubles.  Acute  rheumatism  is  a  disease 
which  begins  suddenly  with  fever,  sore  throat,  and  pains 
in  the  larger  joints,  which,  in  turn,  become  swollen,  hot, 
and  exceedingly  tender.  In  four-fifths  of  the  cases  of 
rheumatic  fever  tonsillitis  precedes  or  accompanies  the 
rheumatism.  It  is  the  duty  of  the  tonsils  to  stop  the 
entrance  of  germs  into  the  blood  from  the  throat.  In 
their  attempt  to  do  this  they  themselves  frequently  become 
acutely  or  chronically  diseased,  and  are,  notwithstanding, 
often  unable  to  check  the  invasion  of  bacteria  into  the 
system  at  large.  In  acute  rheumatism  the  germs  find 
their  way  into  the  blood  from  diseased  tonsils,  and  not  only 
attack  the  joints,  but  have  an  affinity  for  the  valves  of  the 
heart  and  lungs,  so  that  valvular  disease  of  the  heart  is  the 
most  common  complication  of  acute  rheumatism,  while 
pneumonia  and  pleurisy  are  not  infrequent  accompani- 
ments. The  whole  train  of  diseases  which  may  end  in 
permanent  disability  of  the  heart  for  life,  or  rapid  fatality 
from  the  acute  attack,  begins  in  the  apparently  harmless 
and  commonplace  tonsillitis.  While  acute  rheumatism 

203 


204  THE    PREVENTION    OF   DISEASE 

is  a  well-defined  and  recognized  special  disease,  the  causa- 
tive germ  is  not  so  well  established.  Recently  (1914), 
however,  it  seems  pretty  well  ascertained  that  it  is  due  to  a 
common  germ,  the  cause  of  many  of  the  most  severe  wound 
inflammations  and  of  the  most  serious  inflammations 
in  many  parts  of  the  body.  The  injection  of  these  germs 
(streptococci)  from  diseased  tonsils  into  animals  has  ex- 
perimentally produced  all  the  symptoms  of  rheumatic 
fever,  with  even  the  heart  complication;  while,  on  the 
other  hand,  the  removal  of  diseased  tonsils  in  man  has 
been  followed  by  complete  recovery  of  acute  and  chronic 
forms  of  rheumatism. 

Extensive  outbreaks  of  acute  tonsillitis  have  of  late 
years  been  traced  to  the  action  of  germs  (streptococci) 
in  milk  derived  from  cows  having  inflammation  of  the 
udder,  or  originating  in  the  throat  of  men  who  convey  the 
germs  to  milk  through  handling  or  tasting  it.  Thus,  in 
Boston,  in  May,  1911,  an  epidemic  began  in  which  there 
were  1048  cases  of  what  was  called  septic  sore  throat,  a 
severe  tonsillitis,  in  which  the  glands,  joints,  lungs  (pneu- 
monia), heart,  kidneys,  and  other  organs  were  also  attacked 
by  the  entrance  of  germs  from  the  tonsils  into  the  general 
circulation.  There  were  forty-eight  deaths  from  these 
complications.  In  this  instance  the  disease  was  traced 
by  Professor  C.  E.  A.  Winslow  to  an  apparently  healthy 
employee  who  was  a  "carrier"  of  streptococci  in  his 
throat.  It  is  practically  impossible  to  avoid  such  occa- 
sional accidents  from  drinking  raw  milk,  and  the  only  safe- 
guard, therefore,  is  the  taking  of  cooked  milk  (see  p.  284). 
Indeed,  the  dairy  responsible  for  this  unfortunate  outbreak 
had  been  celebrated  for  a  generation  as  the  show  dairy  of 
New  England,  and  employed  both  a  sanitarian  and  veter- 
inarian of  the  highest  standing  to  supervise  and  direct  the 
handling  of  the  output. 


PREVENTION    OF    ACUTE    AND    CHRONIC    RHEUMATISM      205 

The  author  at  the  present  moment  of  writing  has  a 
patient  (the  keeper  of  a  small  corner  grocery)  under  his 
care  with  tonsillitis,  and  on  the  fourth  day  of  the  disease 
(today)  he  suddenly  develops  acute  rheumatism  in  his 
knees,  ankles,  and  hands.  Fancy  the  number  of  similar 
cases  he  might  create  by  handling  the  milk  he  sells— if  it 
were  not  in  sealed  bottles — and  by  handling  other  food 
eaten  raw,  as  he  lives  in  the  back  of  his  store. 

Even  in  the  midst  of  rheumatic  fever  it  may  be  best 
to  remove  diseased  tonsils  if  they  are  not  acutely  in- 
flamed. 

While  diseased  tonsils  are  the  chief  cause  of  acute  rheu- 
matism, in  some  cases  other  disorders  of  the  nose,  mouth, 
and  throat  in  which  the  same  germs  are  present  (strepto- 
cocci) may  be  also  causative  factors.  These  include 
abscessed  teeth,  inflamed  gums  or  Riggs'  disease,  catarrhal 
inflammation  in  the  nose  or  in  the  cavities  in  the  face  and 
forehead  (sinuses)  connected  with  the  nasal  passages,  and 
in  inflammation  in  the  back  of  the  nose  favored  by  the 
presence  of  adenoid  growths. 

So  that  these  conditions  must  be  remedied.  But  even 
when  the  germs  in  these  parts  do  not  enter  the  blood,  to 
produce  inflammations  in  other  parts,  it  is  thought  that 
their  toxins  or  poisons  are  absorbed  and  are  sufficient  to 
account  for  the  so-called  growing  pains  in  the  limbs  of 
children.  Moreover,  these  poisons  generated  by  the 
germs  in  diseased  tonsils  and  adenoids  lower  the  whole 
vitality  and  stunt  the  development  in  children  and  render 
them  more  liable  to  germ  diseases  generally. 

Enlarged  Tonsils  and  Adenoids. — In  regard  to  tonsils 
and  adenoid  growths,  it  may  be  said  that  the  presence  of 
either  so  that  they  can  be  plainly  seen  and  felt  is  evidence 
that  they  are  abnormal.  Enlarged  tonsils  may  be  seen  by 
looking  into  the  open  mouth.  There  are  two  membranous 


206  THE    PREVENTION   OF   DISEASE 

folds  on  each  side  of  the  mouth  which  separate  it  from  the 
throat,  and  the  tonsils  (one  on  each  side)  are  situated  in 
the  space  between  the  folds.  In  the  normal  throat  we 
only  see  these  folds  (pillars),  but  if  the  tonsils  are 
enlarged  and  diseased  they  appear  as  rounded  pro- 
jections jutting  out  into  the  throat,  sometimes  being 
so  large  as  to  almost  block  the  entrance  to  the  throat 
(see  Fig.  2,  page  154).  The  amount  of  infection  or 
germ  growth  in  them  can  only  be  determined  by  an 
expert.  The  adenoid  growths  are  situated  at  the  upper 
part  of  the  throat  and  back  of  the  nose  and  are  out  of 
sight.  Their  presence  may  be  discovered  by  the  doctor 
when  he  inserts  a  forefinger  into  the  mouth,  and  then  hooks 
it  up  behind  the  roof  of  the  mouth  till  he  touches  the  top 
of  the  throat,  which  may  also  be  regarded  as  the  back  of 
the  nose.  For,  if  one  should  pass  an  instrument  (held 
horizontally)  into  the  nostril,  and  so  onward  until  it 
touched  the  back  of  the  throat,  it  would  reach  the  location 
of  the  glandular  growth  known  as  adenoids  (see  Fig.  3, 
page  155).  These  produce  frequent  colds  in  children  and 
deafness  and  abscess  in  the  ear  by  blocking  up  the  open- 
ings of  the  passages  which  connect  the  deeper  part  of  the 
ears  with  the  throat. 

Enlarged  tonsils  and  adenoids  are  exceedingly  common 
in  children  and  it  is  not  necessary  to  make  the  uncom- 
fortable examination  to  determine  the  presence  of  ade- 
noids if  enlarged  tonsils  are  seen,  because  the  appearance 
of  enlarged  tonsils  is  sufficient  evidence  of  the  occurrence  of 
adenoids,  since  they  are  practically  always  co-existent. 
The  recent  custom  of  systematic  medical  inspection  of 
school  children  has  done  more  than  anything  else  to  call 
parents'  attention  both  to  the  presence  and  danger  of  dis- 
eased tonsils  and  adenoid  growths.  But  it  is  not  possible 
for  the  inspectors  to  discuss  the  specific  dangers  of  the 


PREVENTION    OF    ACUTE    AND   CHRONIC    RHEUMATISM      207 

condition  which  we  attempt  to  do  here  and  also  in  more 
detail  in  another  section  (see  p.  153). 

In  respect  to  the  prevention  of  rheumatic  fever,  it 
should  be  added  that  besides  the  removal  of  diseased 
tonsils  and  adenoids  and  the  proper  dental  treatment  of 
abscessed  teeth  and  inflamed  gums  (Riggs'  disease),  to- 
gether with  the  cure  of  any  existing  disease  of  the  nasal 
passages  or  cavities  connected  with  them,  there  are  certain 
general  measures  of  importance.  Thus,  the  avoidance  of 
chilling  and  occupations  where  one  is  continually  wet,  the 
wearing  of  clothing  sufficiently  warm  but  not  so'excessive 
as  to  produce  sweating,  and  the  improvement  of  the  general 
health  are  essential.  A  tendency  to  the  disease  appears 
to  be  quite  commonly  hereditary.  Indeed,  in  7  out  of 
every  10  cases  there  is  found  to  be  a  history  of  the  occur- 
rence of  rheumatic  fever  in  the  family  of  the  patient. 
Chorea,  or  St.  Vitus'  dance,  is  apparently  often  due  to  the 
same  germs  infecting  the  nervous  system  as  are  found  in 
the  joints  in  acute  rheumatism.  In  other  words,  it  is 
rheumatic  and  frequently  occurs  with  or  follows  rheumatic 
fever.  St.  Vitus'  dance  is  shown  by  the  presence  of  un- 
controllable jerking  of  the  limbs,  or  grimacing,  and  the 
same  measures  useful  in  preventing  acute  rheumatism 
should  be  employed  for  the  purpose  of  averting  chorea. 

Chronic  rheumatism  is  probably  always  due  to  the 
absorption  of  germs  or  their  poisons  into  the  blood  and 
thence  into  the  joints.  Chronic  rheumatism  is  thus  an 
infection  and  not  due  to  some  imaginary  constitutional 
cause.  In  this  disease,  which  is  given  various  names,  such 
as  rheumatic  gout  and  various  forms  of  arthritis  (inflamma- 
tion of  joints),  there  is  chronic  swelling,  pain,  and  disa- 
bility in  various  joints,  as  in  the  fingers,  knee,  and  spine, 
jaw,  etc.  The  disease  may  begin  acutely  in  several  joints 
with  fever,  or  come  on  gradually  with  increasing  tender- 


208  THE    PREVENTION   OF   DISEASE 

ness,  swelling,  and  pain  in  one  joint,  to  be  followed  by  a 
similar  condition  in  other  joints  at  a  later  period. 

The  more  common  form  is  seen  in  young  or  middle-aged 
women,  where  the  knuckle-joints  of  the  ringers  become  red, 
swollen,  tender,  painful,  and  stiff.  Chronic  rheumatism 
or  rheumatic  gout  has  no  connection  whatever  with  gout. 
In  all  cases  of  chronic  rheumatism  the  same  causes  are 
operative  as  in  acute  rheumatism,  and  the  disease  may  be 
cured  by  removal  of  them.  In  addition  to  the  infections  of 
the  mouth  and  throat,  it  is  possible  for  infections  in  other 
parts  of  the  body  to  produce  the  disease,  as  in  the  case  of 
inflammations  of  the  sexual  organs  in  men  or  women. 
Then  there  is  a  possibility  that  chronic  constipation  or,  as 
the  fashion  dictates,  auto-intoxication  may  lead  to 
chronic  joint  troubles  by  absorption  of  germs  or  their 
poisons  from  the  stagnant  intestinal  contents. 

The  moral  is,  in  all  cases  of  acute  or  chronic  joint  inflam- 
mations to  prosecute  a  most  thorough  search  throughout 
the  body  for  some  focus  of  local  infection.  These  are  more 
commonly  in  the  mouth  and  throat,  as  we  have  seen. 
Prevention  consists,  then,  in  seeing  to  it  individually  that 
one  has  a  normal  mouth  (teeth  and  gums),  throat,  and 
nose,  that  one  may  not  only  escape  rheumatic  troubles,  but 
the  host  of  serious  diseases  in  remote  parts  of  the  body 
which  may  in  time  result  from  apparently  insignificant 
local  causes  of  discomfort  (see  page  145). 

There  are  other  chronic  joint  inflammations  which  come 
on  in  the  course  of  special  germ  diseases  and  are  due  to  the 
joints  becoming  attacked  by  the  specific  organism.  Thus 
there  may  be  such  complications  in  influenza,  gonorrhea, 
syphilis,  tuberculosis,  etc.,  and  the  name  of  the  disease  is 
applied  to  the  disordered  joint,  as  gonorrheal,  syphilitic, 
tuberculous  arthritis,  etc.  All  joint  inflammations  are 
infections  except  those  due  to  injury  or  gout.  Some  are 


PREVENTION    OF    ACUTE    AND    CHRONIC    RHEUMATISM      209 

due  to  unknown  infection,  and  receive  names  according 
to  the  changes  in  the  joints,  but  popularly  are  classed  under 
the  name  of  rheumatism;  others  are  so  unquestionably 
but  a  part  of  a  general  germ  disease  that  they  receive  the 
name  of  the  special  causative  organism. 

Muscular  Rheumatism. — This  is  a  condition  about 
which  we  know  very  little;  that  is,  we  are  ignorant  of  its 
pathology  or  the  morbid  changes  which  occur  in  the 
muscle,  leading  to  sudden  pain,  stiffness,  and  perhaps 
tenderness  on  pressure.  Almost  every  one  is  personally 
familiar  with  the  discomforts  of  stiff  neck  and  lumbago. 
Young  persons  are  more  subject  to  the  former  and  the 
middle  aged  to  the  latter.  A  person  may  awake  and  be 
suddenly  seized  with  the  most  agonizing  pain  on  moving 
the  neck,  or  it  may  come  on  at  any  time  after  exposure  to 
cold,  as  after  getting  out  of  a  cold  bath.  So,  on  lifting  a 
heavy  body  the  middle-aged  man  finds  he  can  hardly 
straighten  up,  or  after  indulging  in  some  sport  which  he 
pursued  when  younger  he  has  to  take  to  his  bed  from  pain 
in  the  muscles  most  concerned.  To  prevent  the  disorder 
one  should  keep  in  training  by  regular  daily  exercise,  as 
one  attack  seems  to  favor  a  recurrence  of  the  trouble. 
Muscular  rheumatism  is  common  in  the  gouty,  who  should 
restrict  the  amount  of  food,  eat  meat  sparingly  and 
never  more  than  once  daily,  and  drink  plenty  of  water 
(see  page  42).  The  avoidance  of  exposure  to  cold  and 
damp  and  of  sitting  in  drafts  when  warm  are  most 
essential. 

There  is  no  connection  between  muscular  rheumatism 
and  rheumatic  fever  or  the  various  forms  of  joint  inflam- 
mation we  have  considered  above,  which  masquerade 
under  the  generic  cloak  of  ignorance  known  as  chronic 
rheumatism.  To  prevent  severe  forms  of  muscular  rheu- 
matism one  should  at  once  resort  to  rest  and  heat  on  the 

14 


210  THE    PREVENTION    OF   DISEASE 

first  warning  pain  in  the  muscle.  Lying  down  with  the 
hot-water  bag  in  stiff  neck  and  lumbago,  and  strapping  of 
the  small  of  the  back  with  surgeon's  adhesive  plaster,  by 
limiting  the  action  of  the  muscles,  secure  the  most  rest 
and  comfort.  Moving  the  bowels  with  two  or  three  com- 
pound cathartic  pills  and  taking  a  few  10-grain  capsules  of 
aspirin,  followed  by  a  whole  glass  of  water,  at  two-hour 
intervals,  may  cut  short  an  acute  attack  of  muscular 
rheumatism,  whether  it  be  in  the  neck,  back,  or  chest. 
Strapping  the  chest  with  plaster  gives  the  most  rest  and 
relief  in  muscular  rheumatism  in  this  region  when  breath- 
ing and  movements  are  painful. 

Muscular  Cramps. — Cramps  in  the  calves  of  the  legs  are 
common  at  night  after  retiring.  These  are  caused  by  some 
form  of  poisoning.  Either  by  the  poisons  generated  in 
the  muscles  from  overfatigue,  or  those  due  to  various 
diseases,  as  diabetes,  gout,  and  chronic  Bright's  disease. 
Such  poisons  as  lead,  arsenic,  and  alcohol  will  also  cause 
muscular  cramps.  Bandaging  the  legs  before  going  to  bed 
will  often  prevent  attacks  when  they  are  due  to  over- 
exertion,  but  when  this  cause  may  be  ruled  out,  the  patient 
should  seek  professional  advice  lest  he  be  a  sufferer  from 
one  of  the  constitutional  conditions  noted. 

ACUTE  TONSILLITIS 

This  is  a  contagious  disease,  and  sKould  be  treated  as 
such,  although  it  has  hitherto  not  been  included  among 
the  diseases  reportable  to  the  health  authorities.  It 
attacks  young  persons  most  frequently  and  all  patients 
should  be  isolated.  Contagion  is  probably  only  acquired 
by  direct  contact  with  the  patient,  as  by  kissing;  or  from 
the  secretions  of  the  nose  and  throat,  as  by  use  of  a 
common  drinking  or  eating  utensil,  towel,  etc.  Therefore 


ACUTE    TONSILLITIS  211 

the  handkerchiefs  should  be  boiled  or,  better,  the  secretion 
from  the  mouth  or  nose  should  be  collected  on  paper  and 
immediately  burned.  The  eating  and  drinking  utensils 
should  be  boiled.  Tonsillitis  is  a  dangerous  disease  on 
account  of  its  frequent  complications,  as  enlarged  glands, 
pneumonia,  valvular  disease  of  the  heart,  acute  Bright's 
disease  of  the  kidneys,  inflamed  joints,  etc.  (see  page  145). 
For  this  reason  one  cannot  teach  the  public  too  often  or 
emphatically  that  it  is  to  be  avoided  by  all  means.  Be- 
cause patients  apparently  more  often  escape  the  dangers  is 


Fig.  5. — Acute  follicular  tonsillitis  (Gleason). 

no  reason  for  making  light  of  them,  especially  as  many  of 
the  complications  occur  so  long  after  the  attacks  of  tonsillitis 
that  they  are  not  attributed  to  their  true  cause  (see  page 
148).  There  is  the  most  peculiar  danger  in  tonsillitis  and 
sore  throat  in  dairy  employees,  as  the  causative  germ  grows 
and  multiplies  most  favorably  in  milk,  so  that  such  patients 
have  not  infrequently  been  the  cause  of  outbreaks  of 
hundreds  of  cases  of  septic  sore  throat  by  infecting  the 
milk  they  handled  (see  page  204). 

The  dairy  employee  with  sore  throat  should  be  im- 
mediately removed  from  work    and  the  local  health  au- 


212  THE    PREVENTION    OF   DISEASE 

thority  notified,  to  protect  both  the  employer  (from  dam- 
ages) and  the  public. 

The  most  useful  measure  to  avoid  acute  tonsillitis  con- 
sists in  painting  the  tonsils  two  or  three  times  with  a  strong 
(10  to  20  per  cent.)  solution  of  silver  nitrate  during  the 
first  day  at  the  first  suggestion  of  sore  throat.  In  the 
very  first  stages  this  may  abort  an  attack,  but  later  it  may 
do  harm  by  shutting  in  the  infection  through  the  coating 
caused  by  the  silver.  This  treatment  should  be  applied 
by  a  physician;  but  persons  subject  to  acute  tonsillitis 
are  also  the  victims  of  chronic  tonsillitis,  and  the  conse- 
quences of  this  condition  are  both  dangerous  and  far  reach- 
ing (see  page  153).  To  avert  these,  and  recurrences  of 
acute  attacks,  the  total  removal  of  the  tonsils  is  com- 
monly the  only  proper  remedy. 

We  cannot  repeat  too  often  that  the  removal  of  the 
tonsils  should  be  surgically  complete.  The  tonsil  clumsily 
removed  in  part  is  often  more  dangerous  to  the  owner  than 
the  tonsil  uncared  for. 


CHAPTER  XI 

THE  PREVENTION  OF  DISEASES  OF  CHILDREN 

WHILE  the  surest  way  to  achieve  longevity  is  to  possess 
long-lived  progenitors,  yet  much  may  be  done  to  secure  a 
useful,  healthy,  and  long  life  by  the  care  given  the  child. 
What  has  already  been  accomplished,  as  affecting  the 
average  duration  of  life  among  civilized  nations  and  in 
diminishing  the  death-rate  in  the  case  of  certain  diseases 
within  a  comparatively  short  space  of  time,  is  most  remark- 
able. The  infant  mortality  has  had  most  to  do  with  statis- 
tics concerning  the  general  death-rates.  If  a  considerable 
part  of  the  population  die  within  the  first  year  of  life, 
the  statistical  average  duration  of  life  will  be  tremendously 
and  misleadingly  altered.  In  computing  averages  it  is 
notorious  that  extremes  have  most  effect.  The  reduction 
in  infant  mortality  is  chiefly  due  to  improvement  in  the 
milk  supply  of  artificially  fed  infants,  so  that  the  diarrheal 
diseases,  or  so-called  summer  complaint  and  cholera  mor- 
bus,  are  in  great  part  extinguished. 

Thus,  in  Rochester,  N.  Y.,  to  give  a  single  instance, 
largely  through  the  efforts  of  the  efficient  Health  Officer, 
Dr.  G.  W.  Goler,  the  infant  mortality  has  been  reduced  as 
follows  through  the  supplying  of  clean  milk  for  infant 
food:  In  the  decade  including  the  years  1887  to  1896, 
before  the  milk  work  was  done,  the  average  mortality  in 
infants  under  one  year  in  the  month  of  July  was  1010;  in 
1897  to  1906,  after  the  milk  work  was  under  way,  the 
average  death-rate  in  babies  was  only  413  in  July  under 
the  same  general  conditions. 

213 


214  THE    PREVENTION    OF   DISEASE 

The  fight  against  tuberculosis  has  been  so  successful 
that,  while  it  has  been  authoritatively  estimated  that  the 
death-rate  from  this  disease  amounted  to  one-fourth  of 
the  whole  population  in  Europe  during  the  last  century, 
at  the  present  time  it  causes  but  one-tenth  of  all  deaths  in 
the  most  enlightened  communities.  The  annual  mortality 
from  all  causes  in  London  in  the  17th  century  was  50  per 
1000,  as  against  15  at  present;  in  Boston,  in  1700,  the  death- 
rate  was  34  and  now  is  19;  and  within  a  century  London, 
Berlin,  and  Munich  have  cut  their  death-rates  in  half. 
Sweden,  with  its  school  gymnastics  and  government- 
installed  hygiene,  has  the  longevity  record  of  the  world; 
the  average  life  duration  of  men  in  Sweden  is  fifty  and  of 
women  fifty-three;  in  the  United  States  it  is  forty-four  for 
men  and  forty-six  for  women;  while  in  India  the  average 
length  of  life  for  men  is  twenty-three  and  for  women  twenty- 
four  years  (Price  Collier).  Seattle  has  the  lowest  death- 
rate  in  the  United  States  (8.37  per  1000),  owing  to  the 
climate,  young  population,  pure  water  and  pure  air 
(clean  streets,  frequent  rain),  and  pure  milk  supply.  The 
absence  of  slums  and  excellence  of  the  health  department 
in  controlling  the  milk  supply  and  infectious  diseases  also 
contribute  to  the  causes  which  give  Seattle  its  unique 
position. 

The  earlier  we  can  begin  with  the  work  of  preventive 
medicine,  the  more  satisfactory  will  be  our  results.  I 
believe  that  there  are  certain  particular  preventive  meas- 
ures which  apply  to  the  generality  of  children  and  which 
all  parents  should  know.  These  I  propose  to  consider  here, 
but  not  necessarily  in  any  great  detail.  To  begin  with  the 
first  weeks  of  the  child's  life: 

The  operation  of  circumcision  for  all  males  is  desirable. 
I  quote  here  from  one  of  our  leading  specialists  in  children's 
diseases,  Dr.  Kerley:  "Should  circumcision  be  practised 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       215 

as  a  routine  measure?  There  is  not  the  slightest  doubt 
that  it  would  be  for  the  best  interest  of  every  male  infant 
if  he  were  circumcised.  The  operation  during  the  second 
week  is  a  trivial  matter.  In  1  out  of  every  5  male 
infants  circumcision  is  a  necessity,  both  for  comfort  and 
health.  In  marked  degrees  of  phimosis  (narrow  or  pin- 
Jiole  opening  in  the  sheath)  it  is  the  only  means  of  relief." 
How  many  parents  there  are  who  begin  by  shirking  this 
simple  method  of  prevention  of  disease.  This  matter  we 
have  already  discussed  under  another  head  (see  page  193) 
and  it  is  unnecessary  to  amplify  it  in  this  place. 

Proper  Food  for  the  Infant. — The  business  of  a  proper 
food  supply  is  the  subject  of  most  consequence  in  the  case 
of  the  newborn  infant.  Of  course,  if  the  mother  can  fur- 
nish this  the  child  is  infinitely  better  off.  In  some  of  the 
older  foundling  asylums  the  mortality  of  newborn  infants 
was  90  per  cent.,  owing  to  our  former  ignorance  in  artificial 
feeding  and  to  the  generally  inferior  physique  of  found- 
lings. 

In  this  place  it  may  not  be  uninteresting  to  present  some 
statistics  concerning  infant  mortality  and  its  causes. 

In  the  United  States  census  of  1900  the  death-rate  for 
every  1000  infants  born  was  highest  in  Charleston,  S.  C., 
being  419.5;  while  in  Washington  it  was  274.5;  in  Balti- 
more, 235.1;  in  New  York,  189.4.  According  to  the  1910 
census  for  every  1000  babies  born,  there  were  deaths 
under  one  year  of  age  as  follows :  Seattle  led  all  the  country 
with  but  79;  Rochester,  N.  Y.,  came  next,  with  86  deaths; 
while  in  the  larger  cities  the  deaths  rose  to  217  in  Boston, 
and  a  still  greater  number  in  the  largest  cities. 

Again,  figuring  the  deaths  in  infants  under  one  year  of 
age  to  every  1000  of  population  according  to  the  1910 
census,  we  have  the  following  results:  Seattle  shows  its 
leadership  once  more  with  1.66  deaths,  and  these  increase 


216  THE   PREVENTION    OF   DISEASE 

in  number  until  we  reach  the  larger  cities,  as  Boston  with 
3.34  deaths;  New  York  with  3.67,  and  Baltimore  with  3.84 
deaths. 

Russia  has  the  highest  infant  mortality,  and  fully  half 
the  infants  die  during  the  first  year  of  life  in  many  districts. 
In  Germany  about  one-fifth  of  the  infants  die  during  their 
first  year.  About  one-half  of  the  deaths  in  infants  under 
one  year  of  age  are  due  to  diarrheal  diseases,  and  these  are 
chiefly  caused  by  germ-laden  cows'  milk.  Among  babies 
who  die,  about  90  per  cent,  are  fed  with  cows'  milk  and  10 
per  cent,  are  fed  from  their  mothers'  breasts,  according  to 
Charles  Harrington's  German  statistics. 

It  has  been  abundantly  proved  that  the  importance  of 
having  cows'  milk  comparatively  free  from  germs  greatly 
transcends  the  matter  of  its  chemical  identity  with  mothers' 
milk. 

When  the  author  first  began  his  milk  work  in  Seattle, 
some  ten  years  ago,  the  mortality  of  babies  under  one  year 
of  age  per  1000  births  was  very  nearly  120,  as  compared  to 
66  in  1913.  Owing  to  the  production  of  certified  milk  by 
several  farms,  and  to  the  popular  interest  in  clean  milk 
aroused  by  our  writings  and  labors,  and  later  to  most 
excellent  work  of  the  former  Health  Officer  (Dr.  Crichton), 
and  of  the  present  Health  Commissioner  (Dr.  McBride), 
the  general  quality  of  the  milk  supply  has  so  improved  that 
Seattle  leads  the  country  in  this  respect,  and  has  taken 
several  first  prizes  for  certified  and  market  milk  at  the 
National  Dairy  Shows.  One  advantage  we  have  consists 
in  the  cool  weather  in  summer,  and  this  is  not  only  directly 
more  favorable  to  infant  health,  but  prevents  the  growth 
of  germs  in  milk  which  is  not  properly  cooled  and  kept  cool. 
Still,  the  reduction  of  the  infant  mortality  by  one-half  in  a 
decade  may  be  attributed  chiefly  to  the  improvement  in 
the  milk-supply  alone,  as  the  climate  has  naturally  re- 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       217 

mained  the  same,  and  no  other  new  factors  of  importance 
have  obtained. 

The  remarkable  showing  of  Rochester,  N.  Y.,  in  her 
pioneer  work  is  all  the  more  creditable,  since  that  city  has 
to  contend  with  much  hotter  weather  than  Seattle  ever  has. 

The  means  by  which  one  can  secure  a  pure  milk  supply 
have  been  described  in  another  section  (see  page  284) .  The 
method  of  artificial  feeding  of  babies  with  cows'  milk  by 
"modified"  milk  has  been  most  popular  in  the  United 
States.  This  aims  at  so  altering  the  chemical  composition 
of  cows'  milk  that  it  will,  chemically,  closely  resemble 
human  milk. 

In  a  general  way  this  result  is  accomplished  by  diluting 
the  upper  part  of  milk  (top-milk  or  cream),  after  standing 
in  bottles,  with  water  or  barley-water.  Since  cows'  milk 
contains  less  sugar,  about  the  same  amount  of  fat,  and 
much  more  casein  or  curd  than  human  milk,  by  diluting  a 
rich  cow's  milk  with  water  we  may  obtain  the  right  per- 
centage of  fat  and  at  the  same  time  reduce  the  normal 
quantity  of  casein,  so  that  it  will  coincide  with  that  natural 
to  human  milk.  In  this  process  the  sugar  is  diluted,  and 
this  loss  is  made  good  by  the  addition  of  milk-sugar  to  the 
mixture.  The  various  methods  of  feeding  babies  will  not 
concern  us  in  this  book,  but,  besides  all  professional  advice 
which  can  be  obtained,  it  is  well  for  all  mothers  to  possess 
a  good  book  devoted  to  the  care  of  babies,  among  which 
Holt's  is  the  accepted  classical  work. 

The  United  States  Public  Health  Service  is  endeavoring 
to  promulgate  through  its  publications  a  much  simpler 
method  of  feeding  babies  than  with  modified  milk.  Skimmed 
milk  should  be  fed  only  during  the  first  week  of  life.  At  the 
beginning  of  the  second  week  one  part  whole  milk  and  two 
parts  skimmed  milk  are  given.  After  the  end  of  the  second 
week  one  will  use  half  whole  milk  and  half  skimmed  milk, 


218  THE   PREVENTION    OF   DISEASE 

while  during  the  fourth  week  a  mixture  of  three  parts  whole 
milk  and  one  part  skimmed  milk  is  given.  Beginning  with 
the  second  month,  whole  milk  is  fed,  but  this  should  not 
contain  over  3  per  cent,  of  fat.  Cities  require  that  milk 
shall  contain  more  than  this  amount  of  fat,  although  some 
Holstein  cows  give  milk  containing  less.  One  must  find 
out  from  one's  milkman  or  city  authorities  what  is  the 
fat  content  of  the  milk  to  be  used,  and  then  take  some  of  it 
off  to  leave  a  milk  containing  only  3  per  cent,  of  fat. 

Thus,  from  a  quart  of  milk,  after  standing  four  hours, 
which  contains  4  per  cent,  of  fat,  remove  the  upper  if 
ounces  (4  tablespoonfuls) ;  from  a  quart  of  milk  containing 
4.5  per  cent,  of  fat,  remove  the  upper  5  tablespoonfuls; 
and  from  milk  containing  5  per  cent,  of  fat,  remove  the 
upper  seven  tablespoonfuls,  to  get  a  3  per  cent.  milk. 
The  amount  of  milk  which  is  fed  daily  should  be  equal  to 
one-seventh  of  the  weight  of  the  baby  up  to  three  months 
of  age;  one-eighth  of  the  weight,  from  three  to  six  months; 
and  after  that  from  one-ninth  to  one-tenth  of  the  infant's 
weight.  Thusr  for  a  month  old  baby  who  weighs  9 
pounds,  or  144  ounces,  one  would  use  one-seventh  of  this, 
or  20  ounces  divided  into  eight  feedings,  given  in  the 
twenty-four  hours.  Each  feeding  consists  of  2\  ounces 
supplied  at  intervals  of  two  and  one-half  hours,  although 
more  milk  may  be  given  at  a  feeding  if  the  baby  demands  it. 
This  arrangement  permits  of  a  nap  of  at  least  four  hours  in 
the  night,  and  it  may  be  extended  to  seven  hours — from 
10  P.  M.  to  5  A.  M. — by  training,  in  which  case  the  amount 
in  each  bottle  may  be  increased  so  as  to  give  20  ounces  in 
the  twenty-four  hours. 

During  the  first  three  months  the  milk  should  be  boiled 
by  filling  the  milk  bottles  for  twenty-four  hours'  use, 
stoppering  them  with  absorbent  cotton,  standing  them  in 
boiling  water  to  their  necks,  and  boiling  them  for  three- 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       219 

quarters  of  an  hour.  Then  the  bottles  are  to  be  taken  out, 
cooled  in  cold  water,  and  kept  on  ice.  After  the  third 
month  the  milk  should  be  pasteurized  as  described  on  page 
287.  Boiling  the  milk  makes  it  more  digestible  by  pre- 
venting the  formation  of  tough  curds  in  the  child's  stom- 
ach.1 

This  method  of  feeding  babies  from  birth  with  boiled 
sk'mmed  milk  and  then  with  gradually  increasing  amounts 
of  whole  milk,  until  at  the  beginning  of  the  second  month 
of  life  whole  milk  containing  3  per  cent,  of  fat  is  given  ex- 
clusively, has  been  extensively  used  abroad  and  has  been 
found  by  the  writer  suitable  in  most  healthy  babies.  It  has 
the  merit  of  great  simplicity  compared  with  the  modifica- 
tions more  commonly  employed,  such  as  the  additions  of 
varying  amounts  of  cream,  milk-sugar  or  malt  sugar,  barley- 
water,  water,  and  lime-water,  the  proportions  of  the  differ- 
ent ingredients  requiring  constant  changing  from  time  to 
time.  Recent  researches  have  shown  that  it  is  not  the 
large  amount  of  curd  or  casein  in  cows'  milk  which  is 
difficult  of  digestion  for  babies,  as  formerly  held,  but,  on 
the  contrary,  it  is  the  fat  of  cows'  milk  which  usually  dis- 
agrees and  gives  rise  to  apparent  curds  (in  reality,  soap)  in 
the  bowel  discharges.  This  discovery  removes  the  original 
scientific  basis  of  modified  milk,  although  many  of  the 
modern  modifications,  produce  a  result  very  similar  to  the 
whole  milk  containing  3  per  cent,  of  fat.  But  it  must  be 
distinctly  understood  that  no  one  dilution  or  modification 
of  cows'  milk  will  agree  with  all  infants,  and  in  many  cases 
the  most  careful  study  of  the  expert  is  required  to  arrive 
at  the  particular  combination  of  the  chief  ingredients  of 
milk  which  will  best  suit  a  baby  with  delicate  digestion. 

1  Two  teaspoonfuls  of  freshly  prepared  orange  juice  should  be 
given  the  baby  twice  a  day  about  an  hour  before  the  milk  feeding 
(see  pages  220,  221,  303). 


220  THE   PREVENTION   OF  DISEASE 

The  great  desideratum,  however,  is  that  the  milk  be 
clean — as  free  from  germs  as  possible.  Even  if  one  uses  a 
milk  which  does  not  agree  with  the  baby,  so  that  it  is 
fretful,  does  not  gain,  vomits,  or  is  constipated  and  has 
abnormal  bowel  discharges  with  curds,  etc.,  there  is  little 
danger,  providing  one  can  secure  professional  advice  as 
to  altering  the  food.  It  is  merely  a  case  of  malassimilation 
or  indigestion. 

Whereas,  if  the  milk  contains  many  germs,  especially 
those  found  in  manure  in  dirty  milk  from  the  bowels  of 
the  cow,  the  baby  may  be  poisoned  beyond  all  help  or,  at 
any  rate,  is  likely  to  be  in  a  fight  for  its  life  lasting  for 
weeks.  Such  were  the  cases  of  summer  diarrhea  and 
cholera  infantum  which  carried  off  the  babies  to  the  ex- 
tent of  fully  one-half  their  number  during  the  first  year  in 
former  days — simply  cases  of  milk  poisoning — and  now  a 
thing  of  the  past  owing  to  production  of  clean  milk  and 
pasteurization.  The  older  teaching  of  the  profession  that 
pasteurized  milk  causes  scurvy,  rickets,  anemia,  and  mal- 
nutrition in  children  is  not  true  when  orange- juice  is 
used.  Dr.  North  has  probably  tried  the  largest  single 
experiment  in  the  world  in  feeding  10,000  babies  on  pas- 
teurized milk.  The  change  from  raw  to  pasteurized  milk 
was  made  in  a  day,  and  no  digestive  disturbances,  mal- 
nutrition, scurvy,  or  rickets  occurred  from  the  change, 
although  the  infants  were  never  put  back  on  raw 
milk. 

With  the  use  of  fresh  orange-juice  daily  during  the  first 
year,  and  the  addition  of  cereals  and  other  food  after  the 
sixth  to  ninth  month,  there  appears  to  be  no  harm  possible 
from  using  pasteurized  milk,  and  no  other  is  given  to  the 
millions  of  babies  brought  up  on  the  continent  of  Europe. 
The  modern  pasteurization,  at  the  low  temperature  of  145° 
F.  for  thirty  minutes,  while  destroying  all  disease  germs,  has 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       221 

been  held  by  leading  authorities  not  to  in  any  way  alter 
the  chemical  or  vital  qualities  of  milk.  Very  recently 
(1915),  however,  Dr.  A.  F.  Hess  has  indubitably  shown 
that  a  mild  form  of  scurvy  occurs  in  many  infants  fed 
exclusively  on  pasteurized  milk  (heated  to-  145°  F.  for 
thirty  minutes)  without  orange-juice.  This  is  more  apt 
to  occur  when  boiled  or  condensed  milk  is  fed.  Orange- 
juice  will  always  prevent  scurvy  from  heated  milk. 
On  the  other  hand,  the  dangers  from  raw  cows'  milk,  even 
the  product  of  the  most  sanitary  stables  of  millionaires  and 
of  dairies  run  like  well-conducted  operating-rooms,  cannot 
be  certainly  avoided,  either  those  originating  in  the  cow  or 
in  the  human  employee  (see  page  204). 

The  food  should  be  adapted  to  each  individual  child  by 
an  expert  and  his  advice  should  be  sought  whenever  pos- 
sible. 

Perhaps  the  method  of  feeding  infants  best  adapted  for 
universal  use  by  the  average  baby  is  that  devised  by  Drs. 
Holt  and  Shaw  and  supported  by  the  authority  of  the 
American  Medical  Association.1  Whole  cows'  milk  is 
diluted  with  water  because  its  fat  and  curd  (or  proteins)  are 
not  so  readily  digested  by  babies  as  the  same  ingredients 
of  human  milk.  Also  because  cows'  milk  contains  more 
than  double  the  percentage  of  proteins  found  in  human 
milk.  Sugar  is  added  because  it  is  a  normal  ingredient  of 
milk.  Cows'  milk  contains  less  than  human  milk  and  when 
cows'  milk  is  diluted  there  is  all  the  more  need  for  adding 
sugar. 

Milk-sugar  or  malt  sugar  should  be  used  for  most  babies. 

l"Save  the  Babies,"  prepared  for  use  in  Baby  Health  Confer- 
ences for  the  Committee  on  Public  Health  Education  Among 
Women,  by  Drs.  L.  Emmett  Holt  and  Henry  L.  K.  Shaw.  Coun- 
cil on  Health  and  Public  Instruction,  American  Medical  Associa- 
tion. 


222  THE    PREVENTION    OF   DISEASE 

Ordinary  sugar  agrees  with  some  infants,  but  accustoms 
them  to  an  overs weet  food.  Lime-water  is  used  because 
it  prevents  the  formation  of  too  hard  a  curd  in  the  infant's 
stomach  or,  in  other  words,  makes  the  cows'  milk  more 
digestible. 

Beginning  on  the  third  day,  the  average  baby  should  be 
given  3  ounces  of  milk  daily,  diluted  with  7  ounces  of 
water.  To  this  should  be  added  1  tablespoonful  of  lime- 
water  and  2  level  teaspoonfuls  of  sugar.  This  should  be 
given  in  seven  feedings. 

At  one  week  the  average  child  requires  5  ounces  of  milk 
daily,  which,  should  be  diluted  with  10  ounces  of  water. 
To  this  should  be  added  1£  even  tablespoonfuls  of  sugar 
and  1  ounce  of  lime-water.  This  should  be  given  in  seven 
feedings.  The  milk  should  be  increased  by  ^  ounce 
about  every  four  days.  The  water  should  be  increased 
by  \  ounce  every  eight  days. 

At  three  months  the  average  child  requires  16  ounces 
of  milk  daily,  which  should  be  diluted  with  16  ounces  of 
water.  To  this  should  be  added  3  tablespoonfuls  of  sugar 
and  2  ounces  of  lime-water.  This  should  be  given  in  six 
feedings.  The  milk  should  be  increased  by  \  ounce 
every  six  days.  The  water  should  be  reduced  by  \  ounce 
about  every  two  weeks. 

At  six  months  the  average  child  requires  24  ounces  of 
milk  daily,  which  should  be  diluted  with  12  ounces  of 
water.  To  this  should  be  added  2  ounces  of  lime-water 
and  3  even  tablespoonfuls  of  sugar.  This  should  be 
given  in  five  feedings.  The  amount  of  milk  should  be 
increased  by  \  ounce  every  week.  The  milk  should  be 
increased  only  if  the  child  is  hungry  and  digesting  his 
food  well.  It  should  not  be  increased  unless  he  is  hungry, 
nor  if  he  is  suffering  from  indigestion,  even  though  he 
seems  hungry. 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       223 

At  nine  months  the  average  child  requires  30  ounces 
of  milk  daily,  which  should  be  diluted  with  10  ounces  of 
water.  To  this  should  be  added  2  even  tablespoonfuls  of 
sugar  and  2  ounces  of  lime-water.  This  should  be  given 
in  five  feedings.  The  sugar  added  may  be  milk-sugar  or  if 
this  cannot  be  obtained  cane  (granulated)  sugar  or  maltose 
(malt  sugar).  At  first  plain  water  should  be  used  to  dilute 
the  milk. 

After  three  months,  sometimes  earlier,  a  weak  barley- 
water  may  be  used  in  the  place  of  plain  water;  it  is  made  of 
|  level  tablespoonful  of  barley  flour  to  16  ounces  of  water 
and  cooked  for  twenty  minutes. 

At  six  months  the  barley  flour  may  be  increased  to  1^ 
even  tablespoonfuls  cooked  in  12  ounces  of  water. 

At  nine  months  the  barley  flour  may  be  increased  to  3 
level  tablespoonfuls  cooked  in  8  ounces  of  water.  The 
milk  mixture  should  be  pasteurized  from  the  start  and 
1  to  2  tablespoonfuls  of  orange-juice  be  given  daily 
(see  page  219). 

System  in  the  bringing  up  of  children  is  of  as  great  im- 
portance as  in  any  other  business  of  life.  There  is  a  proper 
time  for  everything — a  time  for  nursing  or  feeding,  a  time 
for  sleeping  (at  midday  and  at  night),  a  time  for  bathing, 
a  time  for  movement  of  the  bowels,  and  a  time  for  playing. 
If  regularity  is  observed  in  enforcing  the  business  of  these 
times  it  will  be  of  great  service  in  the  development,  growth, 
and  health  of  the  child,  and  the  mother  will  have  much  more 
time  for  her  other  affairs.  The  necessity  for  the  isolation 
of  children,  especially  from  other  young  persons,  at  times 
of  sickness  has  been  noted  elsewhere.  This  is  particu- 
larly desirable  when  the  sick  child  has  fever  (as  shown 
by  a  thermometer)  and  symptoms  of  a  cold  or  stomach 
trouble,  as  many  of  the  contagious  diseases  begin  in  this 
way. 


224  THE    PREVENTION    OF   DISEASE 

Only  recently  some  90  cases  of  measles  were  reported  by 
a  state  health  officer  as  having  originated  from  one  man  who 
went  about  with,  as  he  called  it,  a  bad  cold,  apparently  visit- 
ing every  one  he  knew  and  complaining  of  his  misfortune, 
instead  of  staying  at  home  in  bed  with  measles.  The  diet  in 
infants  should  always  be  reduced  in  the  case  of  any  acute 
disease.  In  breast-fed  babies  this  is  accomplished  by  giving 
the  child  4  to  6  tablespoonfuls  of  barley-water  in  a  bottle 
before  each  nursing.  In  bottle-fed  babies  it  is  a  good  rule  to 
add  an  equal  quantity  of  water  to  the  ordinary  milk  mixture 
given  at  the  time.  There  are  no  fevers  in  children  which 
are  not  benefited  by  sponging  of  the  whole  body  with  tepid 
water  when  the  temperature  is  high  or  over  102.5°  F. 
The  use  of  a  well-lighted,  ventilated,  and  simply  furnished 
room  is  desirable  for  children  with  fevers. 

If  a  child  does  not  develop  satisfactorily,  is  pale,  under 
weight,  and  delicate,  especially  if  he  keeps  his  mouth  open 
during  play  and  sleep,  one  should  immediately  suspect  the 
presence  of  enlarged  tonsils  and  adenoids.  We  have  de- 
scribed their  appearance  and  method  of  detection  in  an- 
other place  (see  page  153). 

At  the  risk  of  repetition,  it  may  not  be  amiss  to  again 
emphasize  the  great  importance  of  their  removal  because 
of  the  probability  of  the  irreparable  damage  which  they 
may  do  the  body.  There  is  no  local  trouble  which  is  at 
the  same  time  so  common  and  has  the  possibility  of  leading 
to  such  wide-spread  disaster.  Enlarged  glands  in  the  neck 
practically  always  are  induced  by  diseased  tonsils  and 
adenoids,  and  the  glands  are  found  to  be  tuberculous  in 
most  cases  if  they  persist  for  many  months.  They,  in 
turn,  are  often  the  forerunners  of  general  tuberculosis  or 
consumption. 

Goiter  is  often  brought  on  by  infection  through  a  dis- 
eased tonsil. 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       225 

Colds  in  the  head  are  favored  by  adenoid  growths,  and 
if  these  are  severe,  deafness  commonly  follows  and  often 
abscess  of  the  ear,  which  may  result  in  abscess  in  the  bone 
of  the  skull  behind  the  ear  (mastoid  abscess),  with  pos- 
sible complications  of  brain  abscess,  permanent  disease 
of  the  ear,  facial  paralysis,  and  all  sorts  of  fearful  pos- 
sibilities. 

Children  who  take  influenza,  diphtheria,  measles,  and 
scarlet  fever  will  be  much  more  likely  to  have  mild  attacks 
and  will  be  freer  from  complications  if  they  are  without 
adenoids  or  disease  of  the  tonsils. 

The  presence  of  adenoids  and  diseased  tonsils  in  a  child 
is  the  most  frequent  cause  of  permanent  valvular  disease 
of  the  heart,  of  rheumatic  fever,  chorea,  or  St.  Vitus' 
dance,  night  terrors,  and  other  nervous  disorders.  Dis- 
orders of  the  kidneys  and  lungs,  as  Bright's  disease  and 
pleurisy,  are  directly  caused  by  diseased  tonsils,  so  that 
it  is  the  unquestionable  duty  of  parents  to  have  enlarged 
and  diseased  tonsils  and  adenoid  growths  removed  in  early 
childhood,  and  removed  in  their  entirety,  and  not,  as  has 
been  the  custom  until  recently,  by  cutting  off  the  tops  of 
the  tonsils  and  leaving  the  stumps  covered  by  a  scar,  so 
imprisoning  the  germs  that  they  are  a  greater  menace  to 
the  body  than  before.  It  is,  therefore,  necessary  that  an 
expert  do  this  simple  operation,  the  results  of  which  may 
be  of  such  extraordinary  value  to  the  patient.  School 
inspection  is  now  the  chief  means  of  emphasizing  the  neces- 
sity of  this  operation  upon  parents,  since  diseased  tonsils 
and  adenoids  produce  dulness  and  backwardness  in  pupils, 
besides  giving  them  a  stupid  expression  through  alteration 
in  the  shape  of  the  jaws,  face,  and  chest  (see  page  153). 
Another  duty  of  the  parents  is  the  care  of  the  teeth,  since 
here  again  it  has  recently  been  discovered  that  the  presence 
of  germs  in  decayed  teeth  may  produce  as  wide-spread 

15 


226  THE    PREVENTION    OF   DISEASE 

disease  as  occurs  in  the  case  of  diseased  tonsils.  The  same 
germs  may  be  present,  and  being  absorbed  into  the  blood 
will  produce  the  same  effects  in  distant  organs. 

The  straightening  of  the  teeth  will  often  greatly  im- 
prove the  appearance  of  the  face  by  widening  the  jaw,  and 
at  the  same  time  increase  the  assimilation  of  food  by  giving 
a  better  grinding  surface,  in  making  the  teeth  of  the  two 
jaws  meet.  Then,  in  widening  the  upper  jaw  by  correcting 
irregularities  in  the  growth  of  the  second  teeth,  one  pre- 
vents the  occurrence  of  a  high,  narrow  palate  which  leads 
to  obstructed  nasal  breathing  or,  in  other  words,  favors 
mouth-breathing  (see  pages  20,  153). 

Vaccination. — The  baby  should  be  vaccinated  against 
small-pox  in  the  early  months  of  life.  The  younger  the 
child,  the  less  severe  is  the  vaccination,  providing  the  sub- 
ject is  over  one  month  old.  We  have  discussed  the  matter 
more  fully  in  another  place  (see  page  77).  Then  the  ques- 
tion of  sexual  hygiene  begins  with  the  birth  of  the  child, 
and  constant  attention  should  be  paid  to  this  matter  until 
the  completion  of  adolescence  (see  page  193). 

Vaccination  for  typhoid  fever  is  also  essential  for  children 
who  live  in  a  section  in  which  the  disease  occurs  or  who 
travel  about. 

In  many  parts  of  the  United  States  most  of  the  inhabit- 
ants have  typhoid  fever,  but  there  is  no  longer  any  excuse 
for  taking  this  long  and  dangerous  disease  (see  page  76). 
Again,  children  living  in  malarial  regions  should  be  given 
quinin  regularly  as  a  preventive  during  the  open  season,  so 
to  speak.  Quinin  is  harmless  and  will  avert  this  weaken- 
ing and  serious  malady  (see  page  107).  Hookworm  disease,  . 
so  common  in  many  parts  of  the  United  States,  may  be 
prevented  by  forbidding  children  to  go  barefoot.  Delicate 
children  should  be  brought  up  as  recommended  for  the 
children  of  nervous  parents,  and  the  same  sort  of  care  will 


THE    PREVENTION    OF    DISEASES    OF    CHILDREN       227 

be  indicated  for  the  offspring  of  tuberculous  progenitors 
(see  page  247). 

Children  who  have  long,  narrow  chests  and  abdomens, 
who  are  thin  and  poorly  developed,  are  inclined  to  stoop, 
and  who  have  shoulder-blades  jutting  out  behind  like 
wings,  with  bellies  large  in  proportion  to  the  rest  of  the 
body  and  most  prominent  in  the  lower  part — these  are 
likely  to  develop  indigestion  and  nervous  troubles  and 
should  receive  special  care  (see  page  276). 

Children  should  be  taught  from  infancy  the  necessity  of 
individual  handkerchiefs,  soap,  towels,  wash-basins,  cloth- 
ing, pencils,  and  eating  and  drinking  utensils.  Some  of  the 
most  serious  eye  troubles,  as  trachoma  or  granular  lids,  are 
usually  acquired  at  school  from  these  articles  used  in  com- 
mon. Even  at  home,  eruptive  diseases,  colds,  tonsillitis, 
diphtheria,  tuberculosis,  etc.,  may  be  communicated  by 
the  common  use  of  these  articles.  It  is  of  the  utmost 
importance  to  instil  the  habit  of  only  using  one's  own 
articles  during  infancy,  so  that  the  child  will  come  to  only 
want  his  own  things,  and  a  habit  will  be  formed  which 
will  endure  and  become  second  nature. 


CHAPTER  XII 

THE  PREVENTION  OF  DISEASES  OF  MIDDLE  AGE 

Arteriosclerosis,  Heart  Disease,  Bright's  Disease  of  the  Kidneys 

IN  this  section  I  shall  chiefly  consider  diseases  of  the 
blood-vessels,  heart,  and  kidneys,  since  these  are  the 
troubles  most  to  be  feared  with  advancing  years.  By  dis- 
ease of  the  blood-vessels  I  refer  to  thickening  of  the  ar- 
teries or,  as  it  is  called  technically,  arteriosclerosis. 

ARTERIO  SCLERO  SIS 

The  blood-vessels  are  not  only  thickened,  their  caliber 
thus  being  lessened,  but  they  degenerate  (hardening)  and 
break  more  readily.  This  process  takes  place  naturally  in 
old  age,  and  is,  therefore,  physiologic.  When  arterioscle- 
rosis occurs  in  youth  or  middle  age  it  is  abnormal  and  leads 
to  many  other  disorders.  Thus,  thickening  of  the  arteries 
is  almost  always  associated  with  disease  of  the  heart  and 
kidneys,  being  either  the  cause  or  result  of  these  maladies. 
The  importance  and  gravity  of  thickening  of  the  arteries 
is  reflected  in  that  trite  medical  maxim,  "a  man  is  as  old  as 
his  blood-vessels." 

The  most  frequent  cause  of  thickening  and  hardening  of 
the  arteries  is  their  overuse.  As  is  the  case  with  any  other 
organ  in  the  body,  overuse  leads  to  overgrowth.  Thus, 
strain  of  the  heart  nature  tries  to  overcome  by  means  of  its 
enlargement.  Strain  of  the  arteries  nature  attempts  to  rem- 
edy by  increasing  their  thickness.  By  strain  of  the  arteries 
is  meant  attempts  at  their  overfilling,  thus  augmenting 

228 


ARTERIOSCLEROSIS  229 

the  pressure  from  within  on  their  walls.  Overuse  of  the 
blood-vessels  is  commonly  seen  in  three  classes  of  persons: 
In  those  who  customarily  undergo  severe  physical  exertion; 
in  those  frequently  exposed  to  nervous  excitement,  and  in 
those  who  habitually  overeat.  The  site  of  the  overuse  of 
arteries  is  apt  to  be  that  in  which  the  thickening  of  the 
arteries  occurs.  Therefore  in  overuse  of  the  muscles  the 
blood-vessels  of  the  limbs  are  most  thickened ;  in  those  sub- 
ject to  nervous  excitement  the  vessels  of  the  brain  and 
heart  are  chiefly  affected;  while  in  those  who  overeat,  the 
vessels  all  over  the  body  may  be  thickened  as  well  as  those 
supplying  the  digestive  organs. 

Thickening  of  the  vessels  in  one  part  of  the  body  may 
not  be  nearly  so  serious  a  matter  as  the  same  trouble  occur- 
ring in  another  part.  In  persons  who  have  undergone 
severe  manual  labor  it  is  common  to  see  hard  and  thickened 
arteries  in  the  limbs.  The  arteries  may  contain  so  much 
lime  that  they  are  almost  bony  tubes  and  show  beautifully 
in  x-ray  plates.  But  a  rupture  of  one  of  these  vessels,  or 
its  partial  obstruction,  does  not  threaten  life  so  nearly  as 
the  break  of  an  artery  of  the  brain  (apoplexy),  or  the  ob- 
struction of  the  artery  which  supplies  the  heart  with  blood, 
when  death  is  immediate.  Both  apoplexy  and  heart  fail- 
ure are  the  common  results  of  arteriosclerosis  in  persons  of 
middle  or  advanced  age. 

Overeating  is  one  of  the  most  frequent  causes  of  arterio- 
sclerosis in  well-to-do  individuals  over  forty.  Overeating 
works  harm  in  various  ways.  Thus,  it  leads  to  overfilling 
of  the  arteries  supplying  the  abdominal  organs,  and  if  these 
become  thickened  and  narrowed  there  is  apt  to  be  increased 
blood-pressure  all  over  the  body.  This  follows  because 
the  abdominal  blood-vessels  form  a  great  natural  reservoir, 
and  in  their  normal  condition  can  hold  all  the  blood  in  the 
body  if  they  are  dilated.  Overeating  of  meat  is  especially 


230  THE   PREVENTION   OF  DISEASE 

injurious,  since  meat  contains  substances  which  tend  to 
raise  blood-pressure,  and  the  kidneys  are  the  organs  which 
chiefly  eliminate  the  end-products  of  meat. 

The  kidneys  are  thus  overworked,  and  disease  of  the 
kidney  is  one  of  the  most  frequent  causes  of  hardening  of 
the  arteries.  Furthermore,  overeating  actually  increases 
the  amount  of  circulating  blood  and,  therefore,  the  pressure 
or  strain  on  the  arteries.  In  this  explanation  one  may  see 
the  common  effects  of  a  vicious  circle.  One  factor  begins 
to  work  harm,  and  in  so  doing  sets  another  agency  into 
action  which  aggravates  the  effect  of  the  first. 

The  nervous  causes  of  arteriosclerosis  are  of  great  im- 
portance. Every  one  is  familiar  with  the  results  of  mental 
emotion  in  causing  changes  in  the  blood-vessels,  as  shown 
by  sudden  pallor  or  blushing  of  the  face.  In  one  case  the 
heart  may  be  temporarily  arrested  and  the  blood-vessels  of 
the  brain  underfilled  (fainting) ;  in  the  other  example  the 
heart  may  be  beating  violently  and  the  arteries  of  the 
head  may  be  overfull.  In  either  instance  there  is  over-  or 
underaction  of  the  blood-vessels  and  heart  due  to  their 
subordination  to  the  control  of  the  nervous  system.  The 
frequent  and  continued  stimulation  of  the  nervous  system, 
with  the  consequent  overuse  of  the  heart  and  blood-vessels, 
is  a  prolific  cause  of  thickening  of  the  arteries  and  of  heart 
disease  through  the  obstruction  to  the  flow  of  blood  in  the 
thickened  artery  of  the  heart  itself.  This  explains  the 
reason  for  the  common  occurrence  of  such  calamities  as 
apoplexy  and  sudden  heart  failure  in  persons  who  are  under 
constant  mental  excitement,  expectation,  hope  deferred, 
anxiety  and  uncertainty  dependent  upon  certain  phases  of 
modern  life,  as  the  endeavor  to  keep  one's  place  in  the 
world,  or  following  a  speculative  business,  or  arduous  pro- 
fession, or  indulging  in  too  frequent  sexual  excitement 
(see  page  187)  or  in  other  dissipations. 


ARTERIOSCLEROSIS  231 

Nervous  strain,  then,  means  heart  and  vessel  strain. 
Heart  and  vessel  strain  signify  overuse  of  the  heart  and 
blood-vessels.  This  results  in  overactivity  of  the  heart 
and  overfilling  of  the  arteries,  with  consequent  thickening 
of  the  blood-vessels  and  enlargement  of  the  heart. 

Then  eventuate  all  kinds  of  troubles  due  to  insufficient 
and  impeded  blood-supply  to  the  various  organs  of  the 
body,  known  to  physicians  by  the  word  "arteriosclerosis," 
and  to  the  public  chiefly  by  the  more  startling  and  ca- 
lamitous results,  as  seen  when  a  brittle,  thickened  blood 
vessel  bursts  in  the  brain  with  unconsciousness  and 
paralysis  (apoplexy  or  a  stroke  of  paralysis),  or  when  the 
heart  gives  out  slowly  or  at  once  through  failure  of  its 
degenerated  muscle  or  obstruction  in  its  own  arteries. 

Obesity  puts  an  extra  strain  on  the  heart,  as  the  require- 
ments are  greater  in  moving  about  and  supplying  with 
blood  a  heavy  body. 

This  strain  is  felt  particularly  in  the  artery  which  sup- 
plies the  heart  with  blood.  Its  consequent  thickening  and 
the  impairment  of  the  circulation  leads  to  weakness  and 
irregularity  of  the  heart  and  the  fearful  heart-pains  (angina 
pectoris)  occurring  in  middle  and  advanced  age.  The  same 
results  may  be  occasioned  by  arteriosclerosis  of  the  vessels 
of  the  heart  from  any  other  cause.  Certain  chemical  sub- 
stances favor  the  production  of  arteriosclerosis.  The  abuse 
of  alcohol  (the  cause  of  25  per  cent,  of  cases  of  arterioscle- 
rosis— Edwards) ,  tobacco,  tea,  and  coffee  may  be  included 
under  this  head,  while  the  poisons  generated  by  the  germs 
of  typhoid  fever,  syphilis,  and  tuberculosis  are  recognized 
as  fertile  causes  of  arteriosclerosis  in  persons  who  have 
suffered  from  these  diseases.  Workers  in  lead  and  the 
subjects  of  gout  and  diabetes  are  also  more  liable  to  disease 
of  the  arteries.  Chronic  constipation  may  induce  hard- 
ening of  the  arteries  through  poisons  resulting  from  the 


232  THE   PREVENTION    OF   DISEASE 

stagnation  of  the  intestinal  contents  and  their  putrefac- 
tion. The  presence  of  colon  bacilli  (normally  inhabiting 
the  intestines)  in  unusual  numbers  may  be  the  cause  of 
intestinal  putrefaction,  as  shown  by  flatulence,  distention, 
and  foul-smelling  bowel  discharges.  The  treatment  con- 
sists in  total  avoidance  of  meat,  fish,  and  fowl  and  the  sub- 
stitution of  a  vegetable  and  fruit  diet,  reinforced  by  a 
liberal  use  of  butter,  cream,  eggs,  and  milk. 

In  addition,  several  glasses  of  buttermilk  should  be  taken 
daily,  and  any  existing  constipation  must  be  overcome. 
High  enemata  once  in  five  days  are  useful.  If  any  form  of 
local  inflammation  is  present,  as  chronic  appendicitis  or 
gall-bladder  trouble,  it  must  be  cured,  as  it  affords  a  local 
nest  for  the  breeding  of  the  colon  bacilli.  Chronic  intes- 
tinal putrefaction  is  of  great  importance,  since  the  absorp- 
tion of  the  poisons  generated  by  the  colon  germs  may  lead 
not  only  to  high  blood-pressure,  hardening  of  the  arteries, 
but  even  to  chronic  Bright's  disease  of  the  kidneys. 
Heredity  is  a  most  important  factor  in  the  production  of 
early  degeneration  of  the  blood-vessels.  If  one  inherits 
poor  material  in  the  structure  of  the  arteries,  they  will  not 
stand  the  wear  and  tear  attendant  on  the  vicissitudes  of  a 
long  life  in  this  vale  of  tears.  The  more  correct  and 
cheerful  view  of  the  matter  is  that  so  characteristically  put 
by  Sir  William  Osier  when,  after  stating  that  whole  families 
show  the  tendency  to  early  arteriosclerosis  through  bad 
material  in  their  vessels,  he  adds,  "more  commonly  the 
arteriosclerosis  results  from  the  bad  use  of  good  vessels." 

Diseases  of  the  kidneys,  as  we  have  already  noted,  is  a 
prolific  cause  of  thickening  of  the  arteries  and  the  highest 
blood-pressures  are  found  in  such  conditions.  This 
brings  us  to  the  relations  of  thickening  of  the  arteries  and 
kidney  disease.  In  general  arterial  thickening  the  kidney 
vessels  and  the  kidney  may  be  involved,  while  in  chronic 


ARTERIOSCLEROSIS  233 

kidney  trouble  (Bright's  disease)  there  is  always  secondary 
thickening  of  the  arteries.  Bright's  disease  is,  therefore, 
either  the  cause  or  effect  of  arteriosclerosis.  Bright's  dis- 
ease is  the  cause  because  much  of  the  kidney  tissue  is 
obliterated  and  the  blood-pressure  must  be  higher  than 
usual  in  order  that  more  blood  may  be  forced  through  the 
small  amount  of  remaining  kidney  tissue,  and  by  this 
means  the  kidneys  may  remove  a  sufficient  amount  of 
waste  matter  from  the  blood.  It  is  nature's  method  of 
compensation,  but  precisely  how  nature  accomplishes  it  is 
still  a  debated  subject.  But  we  do  know  that  the  arteries 
are  thickened  and  weakened,  and  that  the  heart  becomes 
enlarged  in  practically  all  cases  of  chronic  Bright's  disease 
of  the  kidneys. 

It  may  appear  strange  to  the  layman  that  thickening  of 
the  arteries  means  weakening  of  them.  Thickened  arteries 
are  also  degenerated  arteries,  poor  in  quality,  and  do  not 
supply  the  proper  amount  of  blood,  and  are,  moreover, 
likely  to  break.  So  the  enlarged  heart  after  a  time  becomes 
a  weakened,  dilated  heart,  or  fails  through  lack  of  a  proper 
blood-supply  owing  to  the  thickened  arteries  in  the  heart 
itself. 

Blood-pressure  is  the  pressure  of  the  blood  upon  the 
arteries.  The  circulation  may  be  likened  to  an  apparatus 
consisting  of  a  pump  (the  heart)  forcing  a  fluid  (the  blood) 
through  a  system  of  elastic  tubing  (the  arteries).  The 
blood  must  be  under  a  certain  amount  of  pressure  to  be 
forced  through  the  finer  vessels  (capillaries)  which  are  of 
chief  importance  in  bathing  all  the  tissues  with  blood  for 
their  upbuilding  and  removal  of  waste.  A  constant,  high 
blood-pressure  is  one  of  the  most  common  causes  of  thick- 
ening of  the  arteries,  as  we  explained  in  the  beginning. 
We  have  also  seen,  as  a  further  result,  that  disease  of  the 
heart  and  kidneys  follows,  the  artery  of  the  heart  being 


234 


THE    PREVENTION    OF   DISEASE 


itself  diseased,  or  the  heart  being  strained  by  pumping 
blood  through  the  thickened  vessels.  But  thickening  of 
the  vessels  is  not  always  accompanied  by  high  blood-press- 


Fig.  6. — Technic  of  sphygmomanometry  with  the  Stanton  in- 
strument. Blood-pressure  apparatus  attached  to  arm.  On  squeez- 
ing the  smaller  bulb  the  cuff  about  the  arm  is  inflated  and  air- 
pressure  in  chamber  above  mercury  is  increased,  forcing"  the  mer- 
cury up  the  graduated  tube.  At  the  moment  the  pressure  about 
the  arm  is  so  great  as  to  stop  pulse  at  the  wrist  the  point  at  the 
upper  level  of  the  mercury  is  read  off  the  tube.  This  indicates  the 
amount  of  pressure  required  to  shut  off  the  pulse,  which  is  the  same 
above  the  mercury  as  about  the  arm. 


ure,  unless  disease  of  the  abdominal  vessels  is  present  (see 
above)  or  the  kidney  or  heart  becomes  involved. 

In  high  blood-pressure  we  look,  therefore,  for  arterial, 
heart,  or  kidney  disease,  alone  or  in  combination.     There 


ARTERIOSCLEROSIS 


235 


are  many  cases,  however,  in  which  no  disease  of  either  of 
these  organs  can  be  detected  in  patients  with  high  blood- 
pressure,  and  these  may  be  most  benefited  by  proper 
treatment.  It  should  be  added  that  the  highest  blood- 
pressures  are  seen  in  head  injuries  and  disease  where  there 
is  pressure  on  the  brain. 

The  estimation  of  blood-pressure  has  become  an  impor- 
tant aid  to  diagnosis  in  recent  years,  as  by  its  means  we 
have  an  accurate  method  of  determining  the  tension  of  the 


Fig.  7. — Rogers'  sphygmomanometer.  Another  form  of  blood- 
pressure  apparatus  in  which  the  air-pressure  is  indicated  by  a  hand 
on  a  dial  as  in  an  aneroid  barometer.  More  convenient  but  less 
accurate  (Morrow). 

artery,  while  the  older  method  of  guessing  by  feeling  the 
pulse  has  been  shown  most  ridiculously  unreliable.  In  the 
popular  mind  the  real  import  of  blood-pressure  per  se  is 
probably  unduly  exaggerated.  A  recent  English  writer 
on  America  thinks  we  are  given  to  fads  about  our  physical 
ailments,  and  states  that  some  years  ago,  during  a  visit, 
everybody  was  talking  about  his  or  her  appendix,  but  now 
it  is  their  blood-pressure,  and  many  persons  with  whom  she 
came  in  contact  had  their  own  instruments  and  took  their 
own  blood-pressures  several  times  a  day. 


236  THE    PREVENTION    OF   DISEASE 

Blood-pressure  is  actually  obtained  in  practice  by  blow- 
ing up  a  wide,  hollow,  rubber  cuff,  which  wholly  encircles 
the  arm  above  the  elbow,  until  it  compresses  the  arteries  so 
that  the  pulse  is  obliterated  in  the  wrist.  The  interior  of 
the  hollow  cuff  is  connected  either  with  a  column  of  mer- 
cury or  with  an  aneroid  barometer,  so  that  in  either  case 
the  observer  (with  his  fingers  on  the  pulse  in  the  wrist  of 
the  patient)  notes  the  height  of  the  column  of  mercury,  or 
the  position  of  the  hand  on  the  dial,  at  the  moment  that 
the  pulse  in  the  wrist  is  arrested  by  the  pressure  of  the  cuff 
on  the  arm.  The  normal  blood-pressure  varies  between 
the  figures  120  and  140.  These  are  merely  figures  repre- 
senting the  height  to  which  the  column  of  mercury  ascends 
(measured  in  millimeters),  as  found  by  practice  in  the  use 
of  the  instrument  in  vast  numbers  of  healthy  individuals. 

HEART  DISEASE 

There  are  four  common  causes  of  heart  disease.  Two  of 
these  we  have  just  considered;  that  is,  disease  of  the  blood- 
vessels and  kidneys.  We  have  found  disease  of  these 
organs  commonly  associated. 

The  most  frequent  cause  of  valvular  and  other  diseases 
of  the  heart  in  young  persons,  and  more  often  in  young 
women,  is  acute  rheumatism. 

This  form  of  heart  disease  follows  attacks  of  tonsillitis 
and  frequently  rheumatic  fever,  and  may  be  associated 
with  St.  Vitus'  dance.  All  three  troubles  are  due  to  infec- 
tion by  a  special  germ  originating  in  inflammation  of  the 
tonsils,  and  all  may  be  prevented  by  removal  of  the  tonsils 
(see  page  145).  The  fourth  cause  of  heart  disease  is 
syphilis,  the  heart  trouble  occurring  more  usually  in  middle- 
aged  men  and  seldom  susceptible  of  cure. 

The  heart  is  weakened,  dilated,  and  diseased  (usually 


BRIGHT'S  DISEASE  237 

temporarily)  in  any  of  the  acute  germ  disorders,  especially 
so  by  diphtheria,  grip,  and  pneumonia. 

This  result  follows  the  action  of  the  germs,  or  poisons 
formed  by  the  germs  of  these  maladies.  A  cure  is  usually 
possible  by  means  of  absolute  rest,  the  patient  remaining 
flat  on  his  back  in  bed  until  the  doctor  finds  that  it  is 
safe  for  the  patient  to  sit  up.  This  is  particularly  true  of 
old  persons,  and  sudden  deaths  following  grip  in  the  aged 
occur  simply  because  the  patients  get  on  their  feet  too 
soon. 

Any  disease  causing  obstruction  to  free  circulation  of 
blood  in  the  lungs  may  produce  disease  of  the  heart  from  its 
overstrain.  All  the  blood  in  the  body  is  first  pumped  from 
the  heart  through  the  lungs,  where  it  is  supplied  with  oxy- 
gen, before  it  returns  to  the  heart  for  distribution  to  the 
rest  of  the  body.  Disease,  as  tuberculosis,  which  obstructs 
the  blood-vessels  in  the  lungs  will,  of  course,  greatly  in- 
crease the  resistance  in  the  lungs  to  blood  forced  through 
them  by  the  heart. 

BRIGHT'S  DISEASE 

Chronic  inflammation  of  the  kidneys,  commonly  called 
Bright's  disease,  is,  as  we  have  seen,  often  part  and  parcel 
of  disease  of  the  blood-vessels.  In  younger  persons  it  is 
caused  by  the  poisons  of  acute  germ  diseases,  particularly 
scarlet  fever,  and  that  produced  in  some  cases  (toxemia)  of 
pregnancy. 

The  same  germs  responsible  for  tonsillitis,  rheumatism, 
and  heart  disease  may  induce  disease  of  the  kidney  as  well. 
The  remedy  is  simple  (see  page  145).  Some  of  the  same 
chemical  poisons  mentioned  as  favoring  arteriosclerosis 
may  lead  to  inflammation  of  the  kidneys.  Alcohol,  ether, 
chloroform,  and  other  drugs  are  included  in  this  group. 

It  is  possible  that  poisons  generated  in  the  course  of 


238  THE    PREVENTION   OF   DISEASE 

chronic  constipation  may  be  a  factor  in  the  production  of 
Bright's  disease,  as  in  arteriosclerosis.  Exposure  to  cold 
is  an  exciting  cause  of  kidney  trouble  because  the  blood 
leaves  the  surface  and  tends  to  produce  congestion  in  the 
kidneys. 

With  the  exception  of  special  individual  causes,  noted  in 
relation  to  disease  of  the  heart  and  kidneys,  the  considera- 
tion of  prevention  of  disease  of  the  vessels,  heart,  and 
kidneys  will  be  treated  under  one  head,  as  many  of  the 
causes  are  common  to  all  three  diseases. 

PREVENTION 

It  is  probable  that  no  book  advice  looking  toward  the 
prevention  of  the  diseases  of  middle  age  would  be  so  valu- 
able as  the  advice  to  consult  a  physician.  This  sounds 
banal,  but  the  author  refers  to  a  custom  which  should  be 
generally  established,  whereby  every  person  should  re- 
ceive a  thorough  annual  physical  examination,  especially 
after  the  age  of  forty.  The  establishment  of  state  health 
officers  for  the  purpose  of  keeping  people  well,  rather  than 
trying  to  patch  them  up  when  sick,  is  more  or  less  in  use  in 
Europe,  and  is  sure  to  be  extended  as  time  goes  on. 

Some  of  the  large  life  insurance  companies  in  this  country 
are  examining  their  policy  holders  without  charge  at  stated 
intervals  as  a  matter  of  economy. 

It  is  not  at  all  uncommon  for  a  person,  conscientiously 
presenting  himself  as  a  good  risk  for  life  insurance  examina- 
tion, to  find  that  he  is  the  subject  of  Bright's  disease,  heart 
trouble,  arteriosclerosis,  or  diabetes,  much  to  his  surprise 
and  distress. 

But  knowledge  of  the  existence  of  a  serious  disease,  after 
the  first  alarm  passes,  is  of  greatest  value  in  the  early  stages 
when  much  may  be  done  to  mitigate  the  symptoms  and 
to  prolong  the  life  of  the  patient.  In  fact,  though  the 


PREVENTION  239 

sound  of  Bright's  disease  and  other  well-known  serious 
maladies  strikes  terror  to  the  heart  of  the  subject  when  he 
hears  such  a  verdict  officially  announced,  yet  the  name 
itself  does  not  mean  much.  The  outlook  in  any  individual 
case  depends  upon  many  factors.  It  is  recognized  that 
persons  with  well-marked  cases  of  Bright's  disease  may 
live  for  twenty  years  or  more  in  comparative  health,  and 
individuals  with  diabetes  often  attain  a  comfortable  old 
age  if  they  can  properly  care  for  themselves. 

Modern  methods  of  diagnosis  are  so  much  more  delicate 
and  precise  than  formerly  that  it  is  possible  to  detect  dis- 
ease in  its  early  stages  long  before  such  a  diagnosis  could 
have  been  made,  even  a  few  years  ago.  The  discovery  of 
the  blood-pressure  instrument,  for  example,  has  been  of 
the  greatest  importance  in  enabling  doctors  to  warn  their 
patients  against  the  dangers  of  arteriosclerosis  and  its 
consequent  brain,  heart,  and  kidney  troubles. 

The  prevention  of  hardening  of  the  arteries  or,  in  other 
words,  the  attainment  of  old  age  cannot  be  consummated 
by  any  new  or  mysterious  means.  "A  quiet,  well-regulated 
life"  is  the  chief  desideratum. 

Quiet,  perhaps  the  most  difficult  of  attainment,  ranks  of 
first  import  in  the  prevention  of  arteriosclerosis.  This 
means  abstention  from  hurry  and  worry,  from  anxiety 
and  nervous  tension,  from  overwork  and  overexcitement. 
The  effects  of  nervous  influences  upon  the  blood-vessels 
and  heart  are  shown  so  graphically,  by  the  blood-pressure 
apparatus  that  he  who  runs  may  read.  The  blood-pressure 
in  an  impressionable  woman  rose  from  130  to  180  after 
receiving  some  bad  news.  It  fell  a  like  amount  in  the  case 
of  a  criminal  given  a  reprieve  from  death  at  the  last  mo- 
ment. A  rise  of  40  is  recorded  in  the  person  of  a  foreigner 
who  thought  he  was  to  have  his  leg  amputated  simply  be- 
cause he  was  taken  into  an  operating-room  for  removal  of  a 


240  THE    PREVENTION    OF   DISEASE 

surgical  dressing.  A  patient  of  the  writer's,  having  a  high 
blood-pressure,  was  taken  into  an  operating-room  to  have 
some  stitches  removed  after  a  capital  operation,  and  be- 
came excited  to  such  a  degree  that  his  blood-pressure  was 
raised  suddenly  to  the  point  that  a  blood-vessel  broke  in 
his  brain.  He  became  at  once  unconscious  from  the 
pressure  of  the  blood-clot  on  his  brain  (apoplexy)  and  died 
within  a  few  hours  after  having  recovered  from  the  effects 
of  a  tremendous  surgical  operation.  It  must  be  freely 
admitted  that  it  is  much  easier  to  point  out  the  cause  than 
to  achieve  its  removal.  But  "where  there's  a  will  there's 
a  way"  will  apply  to  many  persons. 

The  diet  is  of  great  importance.  Moderation  is  the 
first  concern  in  persons  over  forty.  Eat  less,  and  particu- 
larly less  meat.  Meat  is  largely  composed  of  protein. 
This  is  the  chief  nutrient  in  many  of  the  vegetable  foods 
(especially  dried  peas  and  beans)  and  in  fish,  eggs,  cheese, 
and  milk,  and  it  acts  the  same  whether  it  be  taken  in  any 
of  these  foods.  There  is  probably  no  difference  in  the  ac- 
tion of  white  meat  or  dark  meat,  according  to  the  best 
authorities.  The  reasons  for  middle-aged  persons  not 
eating  much  meat  are  several:  First,  because  meats  are 
among  the  most  palatable  foods,  are  very  rich  in  protein, 
and  are  apt,  therefore,  to  be  eaten  too  largely.  Second, 
meats  are  more  prone  to  cause  intestinal  putrefaction  than 
other  foods.  Furthermore,  there  are  two  other  bodies  in 
meat  not  found  in  fruits  or  vegetables,1  milk,  cheese,  or 
eggs,  and  these  are  the  harmful  so-called  extractives 
which  exist  in  large  quantities  in  meat  extracts  and  clear 
soup;  and  allied  substances  known  as  purins  which  are  the 
cause  of  gout,  and  are  found  in  greatest  amount  in  liver, 
brain,  kidneys,  and  pancreas.  Both  these  substances 
favor  arteriosclerosis,  so  that  a  moderate  amount  of  meat 
1  Except  in  slight  quantities,  and  as  noted  below. 


PREVENTION  241 

once  daily  is  sufficient,  and  when  there  is  any  marked 
change  in  the  vessels  or  suspicion  of  kidney  trouble,  meat 
should  be  largely  excluded  from  the  diet  and  the  protein 
element  in  food  be  taken  in  the  form  of  milk,  eggs,  and  vege- 
tables (excluding  dried  peas  and  beans  or  soups  made  from 
them).  In  such  cases  it  is  best  that  neither  fish  nor  eggs 
be  taken  the  same  day  that  meat  is  eaten,  nor  is  it  wise  to 
eat  eggs  and  fish  both  on  the  same  day.  Two  or  three 
glasses  of  milk  daily  maybe  drunk  to  advantage,  and  a  glass 
of  milk  is  equal  in  nourishment  to  two  slices  of  bread  or  to 
two  moderate-sized  potatoes,  or  a  generous  helping  of 
meat.  In  other  words,  the  ideal  diet  for  persons  of 
middle  age  and  past  should  be  composed  chiefly  of  fruits, 
vegetables  (except  dried  peas  and  beans),  cereals,  eggs, 
and  milk,  with  a  minimum  of  fish  or  meat. 

In  regard  to  diet  in  arteriosclerosis,  Sir  William  Osier 
says:  "He  will  often  be  surprised  to  find  that  it  is  one-third 
or  one-fourth  of  that  which  he  has  been  taking  (i.  e.,  'the 
minimum  on  which  he  can  maintain  mental  and  bodily 
vigor').  He  may  take  a  cup  of  tea,  a  boiled  egg,  and  a 
couple  of  slices  of  toast  for  breakfast;  a  vegetable  soup  and 
a  rice  pudding  for  luncheon;  a  piece  of  fish,  a  couple  of 
vegetables,  and  stewed  fruit  for  dinner,  with  a  glass  of 
hot  milk  at  night  or  a  bowl  of  bread  and  milk.  With  a 
diet  along  these  lines  an  arteriosclerotic  may  successful^ 
pray  the  prayer  of  Hezekiah,  and  get,  like  him,  a  fifteen- 
year  extension." 

It  might  be  added  that  some  fish  are  rich  in  purins  to 
quite  the  extent  that  they  exist  in  meat,  notably  salmon 
and  halibut.  That  while  most  vegetables  are  poor  in 
purins  and  some  are  purin-free,  as  cabbage,  cauliflower, 
lettuce,  etc.,  there  are  a  few  which  contain  a  consider- 
able amount,  as  dried  peas  and  beans,  asparagus,  and 
onions. 

16 


242  THE    PREVENTION    OF   DISEASE 

Only  the  dried  peas  and  beans  should  be  excluded  be- 
cause of  their  richness  in  both  protein  and  purins.  Onions 
and  asparagus  both  contain  over  90  per  cent,  of  water 
when  cooked. 

The  quantity  of  liquid  taken  is  of  moment.  The  fad  of 
drinking  unlimited  amounts  of  water  is  far  from  desirable 
in  the  middle  aged. 

An  amount  of  fluid  equal  to  8  glasses  or  2  quarts,  in- 
cluding tea,  coffee,  milk,  and  water,  is  about  the  proper 
daily  quantity.  The  drinking  of  too  much  water  overfills 
the  blood-vessels  and  so  strains  them  and  the  heart.  The 
drinking  of  too  little  fluid  is  harmful  in  that  there  is  an 
insufficient  amount  to  dilute  the  material  eliminated  by  the 
kidneys  and  formation  of  stone  in  the  kidney  may  result. 
The  skin  should  be  kept  active  by  daily  warm  baths  taken 
for  five  minutes  at  a  temperature  of  96°  to  100°  F.  Hot 
baths  are  too  depressing.  Warm  baths  may  be  taken 
before  retiring.  They  favor  sleep  and  at  this  time  are 
less  likely  to  render  the  skin  susceptible  to  cold  and  the 
subject  to  colds. 

Cold  baths  put  a  good  deal  of  strain  on  the  heart  and 
contract  the  blood-vessels,  while  warm  baths  tend  to  dilate 
the  blood-vessels  and  reduce  blood-pressure.  In  persons 
with  high  blood-pressure  warm  baths  should  be  taken  twice 
daily.  The  avoidance  of  constipation  is  necessary  and 
this  may  be  secured  as  advised  in  another  place  (see  page 
260).  Straining  during  movement  of  the  bowels  may  raise 
the  blood-pressure  from  140  to  180,  and  apoplexy  is  not 
uncommon  at  such  times.  Then  we  have  noted  the  fact 
that  poisons  derived  from  delayed  putrefactive  intestinal 
contents  may  favor  hardening  of  the  arteries. 

Sufficient  sleep  is  important,  since  rest  is  the  best  cure 
for  arterial  strain.  The  warm  bath  and  a  warm  glass  of 
milk  at  bedtime  may  aid  in  this  respect.  A  hot  bath  will 


PREVENTION  243 

favor  insomnia  because  it  is  apt  to  lead  to  increase  in  the 
blood-supply  of  the  brain.  The  application  of  a  cold 
sponge  or  cloth  to  the  head  may  be  useful  in  persons  taking 
even  a  warm  bath  before  retiring.  In  elderly  individuals 
who  have  a  habit  of  waking  early  in  the  morning  a  nap 
during  the  day  is  advisable. 

Moderate  exercise  is  desirable,  as  in  walking  and  golfing. 
Severe  exercise,  such  as  required  by  tennis  and  swimming, 
etc.,  are  undesirable  in  putting  altogether  too  much 
strain  on  the  arteries  and  heart. 

Swimming  in  cold  water  is  particularly  dangerous  on 
account  of  the  temperature  contracting  the  blood-vessels 
on  the  surface  and  the  strenuous  exertion,  both  necessi- 
tating very  considerable  strain  on  the  vessels  and  heart. 

Alcohol,  tea,  coffee,  and  tobacco  are  all  injurious  in 
those  suffering  from  arteriosclerosis.  Whether  these 
amenities  should  be  absolutely  abstained  from  depends 
largely  on  the  individual  temperament  and  will.  If  their 
extremely  moderate  use,  as  a  single  cup  of  tea  or  coffee  or  a 
single  cigar  daily,  cannot  be  enjoyed  without  the  danger  of 
exceeding  these  limits,  the  only  sensible  course  is  to  abjure 
them  altogether.  The  avoidance  of  chilling  the  body  is 
essential,  as  this  leads  to  marked  changes  in  the  circulation 
and  strain  of  the  blood-vessels.  An  even,  comparatively 
warm,  dry  climate  is  most  conducive  to  health,  and  persons 
living  by  necessity  in  a  cold  climate  should  take  a  vacation 
when  possible  during  the  colder  months  and  visit  a  warmer 
country.  The  wearing  of  wool  underclothing  is  advisable, 
and  some  forms  are  made  which  do  not  cause  irritation  of 
the  skin,  which  has  led  many  persons  to  discard  their  use. 

Finally,  it  may  be  said  that  while  one  should  escape  the 
wear  and  tear  of  life  as  much  as  possible  to  avert  the  effects 
of  the  vessel  changes,  yet  it  is  unwise  to  give  up  active 
work  and  interest  in  pursuits  not  necessarily  involving 


244  THE    PREVENTION   OF   DISEASE 

great  responsibility,  anxiety,  worry,  or  excitement.  The 
surest  way  to  attain  a  rapid  and  genuine  old  age  is  to  "re- 
tire," in  the  popular  meaning  of  the  word.  The  leaders 
in  our  country  today,  as  Charles  W.  Eliot  and  Thomas 
A.  Edison,  are  the  grand  old  men  who  never  retire  except 
from  the  more  arduous  duties  of  life. 

There  are  other  common  diseases  that  threaten  those  in 
middle  or  advanced  life  which  either  cannot  be  appropri- 
ately considered  in  a  work  of  this  kind  or  which  have  been 
discussed  in  other  parts  of  the  book. 

Among  the  latter  may  be  included  cancer  (see  page  160) 
and  prostatic  enlargement,  so  prevalent  among  old  men. 
The  end-results  of  arteriosclerosis — apoplexy,  heart  failure, 
and  Bright's  disease — are  avoided  to  a  considerable  extent 
by  following  the  course  advised  in  this  chapter.  Pneu- 
monia is  one  of  the  most  frequent  causes  of  death  in  old 
people.  One  who  has  lived  in  towns  composed  largely  of 
elderly  people,  and  such  are  not  by  any  means  infrequent 
in  New  England,  will  be  impressed  with  the  great  toll  which 
pneumonia  exacts  in  the  later  winter  months,  especially 
February  and  March.  It  is  probable  that  the  enforced 
confinement  to  the  house  (with  battened  double  windows) 
for  a  long  period  is  the  cause  of  the  lessened  resistance  to 
the  germ  of  pneumonia,  and  also  the  want  of  free  ventila- 
tion permits  the  accumulation  of  the  germs  in  dwelling 
rooms,  as  pneumonia  germs  are  very  common  inhabitants 
of  the  nose  and  throat  in  healthy  persons  and  in  those  with 
head  colds.  When  possible  an  annual  migration  to  a  warm 
climate,  where  an  outdoor  life  may  be  indulged  in,  will  be 
the  best  means  of  prolonging  life. 

It  seems  probable  that  all  the  causes  of  heart,  blood- 
vessel, and  kidney  disease  are  but  predisposing,  except 
germs;  and  we  shall  find  ultimately  that  the  lodgment  of 
germs  (circulating  in  the  blood)  in  these  organs  is  the  direct 


PREVENTION  245 

cause  of  their  disease.  Metchnikoff  long  ago  affirmed  that 
the  changes  in  the  arteries  from  old  age  were  due  to  germ 
growth,  and  recently  Rosenow  has  found  Bright's  disease  of 
the  kidneys  and  valvular  heart  disease  to  be  due  to  direct 
infection  with  germs  from  the  tonsil,  abscessed  teeth,  or 
other  infections. 


CHAPTER  XIII 

THE  PREVENTION   OF  NERVOUS   AND   MENTAL 
DISEASES 

INTRODUCTORY   NOTE 

THIS  chapter  on  the  prevention  of  nervous  and  mental  diseases 
seems  to  embody  in  concise  and  terse  form  the  chief  points  that 
need  emphasis  in  a  discussion  of  such  matters  before  a  popular  audi- 
ence. It  is  admirably  written  and  the  details  as  to  the  manage- 
ment of  the  nervous  child  are  practical  and  sensible. 

I  like  particularly  the  stress  laid  upon  the  sexual  life,  and  upon 
alcohol  and  syphilis  in  relation  to  preventive  nervous  disorders. 

It  is  true  that  from  the  standpoint  of  surgery  correct  diagnosis 
and  operation  may  often  relieve  what  appear  to  be  neurasthenic  or 
hysteric  symptoms;  on  the  other  hand,  the  tendency  seems  to  me  to 
be  to  rely  too  much  on  surgical  procedures,  and  many  operations  are 
unfortunately  performed  which  are  found  to  have  been  unnecessary. 

There  are  many  mental  causes  of  nervous  disorders,  and  the 
physician  needs  to  keep  this  in  view,  as  well  as  all  possible  physical 
features. 

FREDERICK  PETERSON. 

Neurasthenia,    Hysteria,    Paresis,    Dementia    Praecox,    Paranoia, 
Mania,  Melancholia 

Under  this  caption  we  have  in  mind  chiefly  the  preven- 
tion of  functional  nervous  disorders,  especially  neuras- 
thenia or  nervous  prostration  and  hysteria,  together  with 
some  of  the  more  common  forms  of  mental  disorder. 
Unfortunately,  a  defective  nervous  system  is  more  cer- 
tainly inherited  than  any  other  bodily  abnormality.  To 
begin  preventive  treatment  in  the  case  of  the  offspring  of 

246 


PREVENTION    OF   NERVOUS    AND    MENTAL    DISEASES      247 

neurasthenic,  neurotic,  or  "nervous"  parents  one  should 
begin  some  generations  back  to  secure  the  best  results. 
But  the  outlook  is  by  no  means  hopeless,  or  even  precari- 
ous, if  the  children  can  be  reared  in  a  way  to  counteract 
their  probable  inherited  weakness.  If  only  one  parent  is 
neurasthenic,  the  chances  of  nervous  weakness  in  the 
progeny  is  correspondingly  less,  and  if  the  neurasthenia  in 
the  parent  is  acquired  and  has  been  cured  or  improved,  the 
likelihood  of  any  inherited  weakness  in  the  offspring  is 
much  less  than  if  the  parent  had  inherited  the  taint. 

Neurasthenia. — In  neurasthenia  there  is  a  loss  of  ner- 
vous force  and  control.  Persons  with  a  tendency  to  the 
trouble  have  only  a  small  nervous  capital,  and  when  it  is 
heavily  drawn  upon,  through  emotional  or  physical  strain 
of  any  kind,  they  become  nervous  bankrupts. 

Some  nationalities  are  conspicuously  subject  to  neuras- 
thenia, and  these  are  the  Americans,  Hebrews,  Slavs, 
Poles,  and  Russians.  It  is  seen  commonly  in  immigrants 
in  large  cities,  living  in  unhygienic  surroundings  and 
pressed  for  the  necessities  of  life  under  strange  social  and 
economic  conditions.  The  physical  and  mental  strain  is 
too  great  for  their  already  impoverished  physiques.  In 
former  times  the  unfit  perished,  but  now,  owing  to  a  more 
(and  too?)  humane  environment,  many  of  the  unfit  sur- 
vive. 

The  more  common  causes  of  acquired  nervous  break- 
down are  included  in  sexual  agencies;  constant  mental  and 
physical  strain,  care,  and  worry;  poisons,  as  alcohol, 
morphin,  tobacco ;  and  those  generated  by  germs  in  typhoid 
fever,  malaria,  influenza,  and  syphilis.  So  illustrious  and 
sane  an  authority  as  Sir  William  Osier  states  that  sexual 
factors  are  of  "the  first  importance"  in  the  production  of 
the  so-called  neuroses  or  functional  nervous  disorders. 
Some  authors  pass  them  over  as  being  but  unimportant 


248  THE    PREVENTION    OF   DISEASE 

factors  among  a  host  of  causes,  but  the  writer  has  been 
strongly  impressed  with  the  sexual  origin  of  a  large  propor- 
tion of  cases  of  nervous  prostration.  Crile's  theory  of 
nervous  shock,  which  is  largely  accepted  today,  postulates 
the  disturbing  action  of  stimuli  on  the  brain  which  cannot 
be  transformed  into  action  even  when  the  subject  is  un- 
conscious, as  during  a  surgical  operation  under  ether.  He 
finds  that  constant  mental  strain,  or  anxiety,  or  excessive 
muscular  activity  lead  to  actual  microscopic  changes  in  the 
brain,  liver,  and  other  glands  which  result  in  nervous  ex- 
haustion. He  finds  that  when  the  stimulus  to  the  brain 
can  result  in  normal  activity,  as  when  an  animal  is  hurt 
and  escapes,  the  harm  does  not  occur,  but  when  the 
stimuli  may  not  be  turned  into  the  normal  paths  of  ex- 
pression, then  damage  ensues.  Thus,  stimulation  of  the 
sexual  organs  lead  to  nervous  impulses  which  must  be  con- 
stantly repressed  under  civilized  conditions,  but  the 
result  may  be  grave  injury  to  the  nervous  system.  The 
only  remedy  is  to  avoid  undue  sexual  stimulation  until 
such  a  time  as  the  sexual  functions  are  normally  active  and 
productive  in  marriage.  Sexual  excitement  in  marriage 
engagements  results  so  commonly  in  neurasthenia  that  this 
form  has  been  given  a  special  name.  The  emotions  are 
not  so  commonly  and  strongly  influenced  by  any  other 
agency  as  by  the  sexual  passions.  To  quote  Osier  again: 
"Cherchez  la  femme  is  a  safe  rule  in  investigating  a  neu- 
rotic case."  The  reader  is  referred  to  the  section  on  Sexual 
Hygiene  for  more  detailed  consideration  of  this  subject. 

The  treatment  for  the  prevention  of  nervous  disorders 
in  the  susceptible  offspring  of  neurotic  (pertaining  to  the 
nerves)  parents  should  begin  at  birth,  but  as  it  is  just  the 
sort  of  treatment  that  is  most  beneficial  for  any  child, 
there  is  every  reason  for  enforcing  it. 

The   infant   should    have   proper   discipline   from   the 


PREVENTION    OF    NERVOUS    AND    MENTAL   DISEASES      249 

start,  and  not  be  fondled,  held,  or  nursed  every  time  it 
shows  restlessness  or  cries.  As  the  mother  is  often  neu- 
rotic, it  is  important  to.  have  a  kind,  matter-of-fact,  firm 
nurse  who  is  not  given  to  sentimental,  romantic,  or  religious 
tendencies.  Children  should  be  reared  in  the  country  if 
possible.  The  matters  of  proper  food  at  regular  hours, 
abundance  of  sleep,  fresh  air,  and  daily  bathing  are  of 
importance. 

Avoidance  of  all  means  to  indulge  or  literally  "spoil" 
the  child  is,  of  course,  essential.  When  the  child  becomes 
sulky  or  stormy  because  his  wants  are  not  supplied,  it  is 
wise  to  ignore  him  for  a  time  and  show  such  apparent 
sorrow  at  his  behavior  that  the  child  will  himself  repent  and 
then  be  in  a  suitable  mood  to  receive  proper  correction. 
The  sense  of  duty,  obedience,  unselfishness,  self-denial, 
and  responsibility  should  be  inculcated  at  an  early  age. 
Any  tendency  to  brood  over  fancied  slights  inflicted  by 
others  should  •  be  combated  emphatically.  Association 
with  other  children  in  school  and  play  is  essential,  more 
particularly  in  the  case  of  the  "only  child."  Competitive 
games,  walking,  riding,  swimming,  rowing,  tennis,  bicy- 
cling (with  companions)  are  all  desirable. 

Games  requiring  fierce  competition  in  the  presence  of 
audiences  are,  however,  very  undesirable  in  leading  to 
great  mental  and  physical  strain.  School  should  not  be 
begun  before  the  seventh  year,  and  it  is  a  great  question 
what  sort  of  school  is  best.  The  public  schools  are  good 
in  their  democracy  and  competition,  but  represent  a  low 
standard;  the  private  schools  give  more  individual  atten- 
tion and  are  on  a  higher  level,  while  the  small  private  school 
or  tutor  afford  the  greatest  amount  of  individual  attention 
to  the  pupil  and  represent  the  highest  standard  of  instruc- 
tion. Preparatory  schools  in  the  country  offer  by  far  the 
best  environment  for  youth  in  question,  in  affording  compe- 


250  THE    PREVENTION    OF   DISEASE 

tition,  a  high  standard  of  instruction,  and  a  large  degree  of 
individual  attention  from  the  masters  in  the  matter  of 
teaching,  morals,  manners,  physical  training,  and  sports. 
Discipline,  self-confidence,  modesty,  a  sense  of  responsi- 
bility, good  manners,  health,  and  character  are  obtained 
at  such  schools  as  Rugby,  Eton,  and  Harrow,  in  England, 
and  at  Groton,  St.  Mark's,  St.  Paul,  Exeter,  etc.,  in  the 
United  States.  Being  situated  in  the  country,  the  pupils 
are  not  subjected  to  the  unhealthy  attractions  of  the  city, 
and  give  their  time  to  study  and  sport  outdoors,  and  re- 
ceive a  much  more  wholesome  diet  and  training  than  at 
home.  Our  state  universities  are  mostly  located  in 
country  towns,  and  offer  to  a  considerable  degree  the  same 
environment  as  the  large  private  preparatory  schools,  but 
the  co-educational  feature  is  extremely  objectionable.  It 
is  during  the  period  of  puberty  (twelve  to  seventeen)  that 
special  instruction  should  be  given  both  boys  and  girls 
concerning  their  developing  sexual  functions  (see  pages  193, 
202)  to  avoid  the  formation  of  false  ideas  and  bad  habits. 
At  most  of  the  best  preparatory  schools  the  pupils  have  such 
instruction  given  in  the  proper  manner  by  a  physician. 

That  school  should  be  selected  which  subordinates 
book  knowledge  to  the  moral  and  physical  training,  and 
this  is  the  tendency  of  the  great  English  public  schools. 

The  choosing  of  the  proper  kind  of  a  career  is  of  moment. 
It  should  be  one  as  free  as  may  be  from  unusual  strain  and 
worry  and,  preferably,  not  largely  sedentary.  Relaxation 
in  regular  outdoor  sport  is  essential;  also  eight  to  ten 
hours'  sleep.  Indulgence  in  alcohol  is  particularly  undesir- 
able in  nervous  persons,  because  there  is  an  unusual  long- 
ing for  it  at  times  to  supply  temporary  strength  in  bridging 
over  a  period  of  strain. 

The  temptation  to  repeat  the  remedy  is  too  great  to 
allow  of  its  use.  Excess  in  coffee,  tea,  or  tobacco  are  e$- 


PREVENTION    OF    NERVOUS   AND    MENTAL    DISEASES      251 

pecially  prejudicial  to  the  nerves.  The  same  may  be  said 
of  sexual  excess.  The  long  engagement  is  to  be  tabooed, 
and  a  simple  wedding  and  wholesome  honeymoon  in  the 
country  (and  not  a  tiresome  journey)  are  indicated  (see 
page  197).  In  the  case  of  the  woman,  rest,  quiet,  and 
freedom  from  anxiety  are  peculiarly  necessary  during 
menstruation,  pregnancy,  and  following  childbirth.  Early 
consultation  with  a  physician  in  suspected  pregnancy  will 
bften  give  relief  and  a  feeling  of  security.  Prevention  of 
neurasthenia  in  the  adult  is  usually  only  attempted,  after 
an  attack  has  been  experienced.  Treatment  of  local 
troubles  will  often  relieve  the  general  neurasthenia,  and  in 
no  cases  is  a  thorough  physical  examination  from  head  to 
foot  more  essential  to  discover  a  local  trouble  masquerad- 
ing as  nervous  prostration. 

Nervous  prostration,  to  those  who  have  never  experi- 
enced it,  often  seems  an  inexcusable  and  incomprehensible 
mental  state  which  could  be  prevented  by  exercise  of  will 
power  and  common  sense.  It  is  as  real  a  condition  as  a 
toothache  to  the  patient,  and  his  will  power  is  so  weakened 
that  trying  to  exert  it  is  much  like  trying  to  lift  himself  by 
his  own  bootr-straps. 

There  is  loss  of  self-reliance,  and  little  everyday  tasks 
and  responsibilities  become  overwhelming  burdens.  The 
patient  neglects  his  business,  procrastinates,  and  often 
shuns  society.  The  nervous  system  has  no  resistance  and 
is  peculiarly  susceptible  to  every  influence  or  irritation. 
Women  are  often  emotional,  cry  and  throw  themselves 
about,  and  have  suicidal  ideas.  There  is  usually  mental 
depression.  A  feeling  of  pressure  or  constriction  in  the 
back  of  the  head  or  neck,  and  sometimes  in  other  parts  of 
the  head,  is  the  most  common  symptom.  The  patient 
easily  tires  and  sometimes  is  so  exhausted  as  to  be  unable 
to  walk.  Special  fears  are  characteristic,  as  fear  of  being 


252  THE    PREVENTION    OF   DISEASE 

alone,  of  being  in  a  crowd  or  open  place,  of  being  in  the 
cars,  of  lightning,  etc.  The  memory  is  poor.  Sleepless- 
ness is  the  rule.  Pains  may  occur  in  almost  any  organ  and 
part  of  the  body  and  simulate  organic  disease,  and  this  is 
why  a  thorough  physical  examination  is  required  to  surely 
determine  that  the  neurasthenia  is  not  secondary  to  some 
local  trouble.  Correction  of  local  sources  of  irritation,  as 
stated  above,  may  wholly  cure  neurasthenia,  especially  if 
it  is  of  the  acquired  and  not  of  the  inherited  variety: 
Local  disease  of  the  sexual  organs  in  man  is  a  most  frequent 
cause,  as  has  been  already  noted  and  emphasized.  Since 
abdominal  surgery  has  made  the  diagnosis  of  abdominal 
troubles  often  possible  in  diseases  formerly  subject  to 
guesswork,  it  has  been  found  that  many  of  the  so-called 
cases  of  nervous  dyspepsia  were,  in  reality,  due  to  ulcer  of 
the  stomach,  chronic  appendicitis,  etc.  On  the  other  hand, 
many  persons  with  neurasthenia  have  been  subjected  to 
much  surgery  for  suppositious  organic  diseases  which  never 
existed  except  in  the  mind  of  more  or  less  ignorant  or 
mercenary  operators.  The  leading  surgeons  are  always 
on  their  guard  against  falling  into  such  errors. 

The  prevention  of  neurasthenia  means  practically  proper 
living.  Cabot  regards  four  elements  as  essential  to  proper 
living,  and  has  recently  written  a  book  ("What  Men  Live 
By")  in  which  he  amplifies  his  ideas  on  the  practical  appli- 
cation of  these — work,  play,  love,  and  worship.  All  are 
necessary  in  proper  proportion  for  preserving  the  normal 
moral,  mental,  and  physical  state  we  denote  as  "mens 
sana  in  corpore  sano,"  a  healthy  mind  in  a  healthy  body. 
The  older  methods  of  treatment  of  neurasthenia  included 
largely  the  Weir-Mitchell  rest  cure,  in  which  the  patient 
remained  in  bed  for  three  to  six  weeks  in  a  sanatorium  away 
from  home,  in  the  hands  of  a  doctor  and  nurse,  and  was 
stuffed  with  food,  given  massage  and  electricity,  and  kept 


PREVENTION    OF    NERVOUS    AND    MENTAL    DISEASES      253 

away  from  cares  and  worries.  This  treatment  no  man 
would  stand,  and  it  is  usually  inadvisable  except  in  women 
who  are  much  emaciated  and  who  suffer  from  malnutrition. 
The  more  modern  method  is  that  by  which  the  patient  is 
gradually  directed  into  a  normal  manner  of  living  by  find- 
ing some  sort  of  work  which  will  interest  him  or  her,  so  that 
it  will  not  be  drudgery,  and  combining  this  with  a  proper 
amount  of  recreation.  Such  treatment  sounds  very  simple, 
but  it  requires  all  the  tact  and  wisdom  of  an  experienced 
physician  to  guide  a  neurasthenic  person  back  to  health, 
and  there  will  be  required  many  mental  boosts  from  the 
doctor  and  many  relapses  on  the  part  of  the  patient  before 
the  end  is  secured.  This  re-education  is  best  accomplished 
when  the  patient  can  put  himself  in  the  hands  of  the 
physician  specializing  in  this  matter,  and  having  all  the 
facilities  of  a  sanatorium  in  the  country,  with  its  various 
outdoor  and  indoor  arrangements  for  work  and  play. 
Modern  society  is  responsible  for  much  neurasthenia,  es- 
pecially among  women,  owing  to  the  unhealthy  life  which 
results  from  excitement,  late  hours,  the  use  of  alcohol,  and 
lack  of  restful  occupation.  The  "coming  out"  of  the  young 
woman  is  attended  by  so  much  gaiety  and  late  hours  that 
only  the  unusually  strong  female  can  stand  the  ordeal,  and 
when  this  is  combined  with  a  prolonged  round  of  enter- 
tainments prior  to  marriage  and  its  attendant  demands  for 
extra  exertion  and  excitement,  the  whole  culminating  in  a 
final  burst  of  social  pyrotechnics  at  the  wedding,  we  have 
all  the  ingredients  for  producing  a  beautiful  case  of  nervous 
exhaustion  at  the  worst  possible  time. 

Insanity  may  be  defined  as  the  sudden  or  gradual  devel- 
opment in  a  person  of  more  or  less  permanent  peculiarities 
in  thought,  feeling,  and  action.  This  definition  indicates 
a  decided  change  in  the  normal  character  of  the  person, 
whatever  that  may  have  been.  Unfortunately,  heredity  is 


254  THE    PREVENTION    OF   DISEASE 

here  a  more  unquestionable  and  paramount  cause  than  in 
the  case  of  any  other  disease  In  asylums  it  has  been 
found  that  the  history  of  mental  trouble  can  be  traced  in 
the  forebears  of  half  the  inmates,  and  it  is  estimated  that 
from  50  to  70  per  cent,  of  cases  of  mental  trouble  owe  their 
origin  to  inherited  mental  defects.  The  brain  develop- 
ment of  the  child  is  imperfect  owing  to  the  defective 
germ  material  from  the  parents  (egg  of  the  mother,  sperm 
cell  of  the  father).  Observers  have  noted  diminution  in 
the  number,  together  with  imperfect  development  and 
irregularity,  of  the  brain  cells  in  mental  defectives.  Such 
conditions  are  also  produced  by  the  influence  of  alcohol 
on  the  parents  at  the  time  of  conception  of  the  child,  or  bad 
health  of  the  mother  while  she  is  carrying  the  child,  or  dis- 
eases of  the  subject  in  childhood,  such  as  convulsions, 
scarlet  fever,  influenza,  and  meningitis.  The  care  and 
surroundings  of  the  child  and  method  of  its  upbringing  as 
to  diet,  food,  habits,  work,  play,  diseases,  schooling,  and 
home  life  have  naturally  an  important  bearing  in  favoring 
or  hindering  the  advent  of  mental  breakdowns.  If  the 
conditions  are  bad  they  may  be  sufficient  in  themselves  to 
cause  insanity,  and  with  an  added  inherited  taint,  would  be 
pretty  certain  to  do  so. 

Many  immigrants  become  insane  probably  from  their 
unfavorable  environment  alone. 

Causes  of  Insanity. — Bad  habits  are  the  cause  of  about 
one-quarter  of  all  cases  of  insanity,  and  these  include  the 
abuse  of  alcohol,  morphin,  cocain,  and  self-abuse,  but  the 
chief  of  these  is  alcohol.  Alcohol,  in  the  report  of  the  Mas- 
sachusetts Commission  of  19 10  on  the  reason  for  the  increase 
of  criminal  and  mental  defectives,  was  found  the  essential 
cause — "Indeed  it  is  the  belief  of  this  commission,  based 
upon  long  personal  observation,  that  the  abuse  of  alcohol 
directly  and  indirectly  does  more  to  fill  our  prisons,  insane 


PREVENTION    OF    NERVOUS    AND    MENTAL    DISEASES      255 

hospitals,  institutions  for  the  feeble  minded,  and  alms- 
houses  than  all  other  causes  combined.  We  are  unable  to 
formulate  any  recommendations  as  to  legislation  which  we 
believe  would  materially  modify  this  deplorable  condition. 
It  is  probable  that  long-continued  education  of  the  young 
as  to  the  mental,  moral,  physical,  and  economic  results  of 
the  abuse  of  alcohol  will  be  the  most  effective  method  of 
dealing  with  the  subject." 

It  is  hard  for  persons  living  in  refined  and  comfortable 
circumstances  to  realize  the  full  meaning  of  this  opinion, 
but  if  one  actually  sees  the  innumerable  cases  of  delirium 
tremens  which  enter  large  city  hospitals  every  day  of  the 
year,  and  follows  them  into  the  courts  and  thence  into  the 
asylums  (those  who  do  not  stop  at  the  morgue),  its  true 
impressiveness  becomes  very  poignant.  During  holiday 
seasons,  as  about  Christmas  and  New  Years,  the  number 
of  such  cases  is  sickening  and  appalling. 

Alcohol  is  the  cause  of  20  per  cent,  of  all  cases  of  insanity 
according  to  a  well-known  alienist. 

Another  fruitful  but  preventable  cause  of  insanity  is 
syphilis,  which  we  have  stated  elsewhere  (see  page  183)  is 
practically  the  sole  cause  of  locomotor  ataxia  and  paresis 
(or  general  paralysis  of  the  insane,  or  softening  of  the 
brain).  Paresis  occurs  in  middle  life  and  terminates  in 
death  in  three  to  five  years.  About  14  per  cent,  of  the 
inmates  of  New  York  State  hospitals  have  this  disease, 
and  there  are  probably  about  10,000  deaths  in  the  United 
States  annually  from  this  cause,  if  the  same  rate  prevails 
as  in  New  York  State.  Locomotor  ataxia  is  syphilis  of 
the  spinal  cord.  Paresis  is  syphilis  of  the  brain. 

Certain  epochs  are  favorable  for  the  development  of 
insanity.  In  women  the  age  of  puberty  (twelve  to  four- 
teen), pregnancy  and  childbirth,  and  the  period  of  change 
of  life  (forty-five  to  fifty-five)  are  danger  periods;  while  in 


256  THE   PREVENTION    OF   DISEASE 

men  middle  life  (thirty-five  to  fifty)  is  the  more  frequent 
age  at  which  insanity  appears. 

Forms  of  Insanity. — During  youth  one  of  the  com- 
monest forms  of  insanity,  known  as  precocious  dementia 
(dementia  praecox),  begins.  This  is  seen  especially  in 
those  with  hereditary  tendencies  to  mental  or  nervous 
disease  or  in  the  progeny  of  alcoholic  forebears.  Suf- 
ferers from  this  form  of  mental  impairment  are  long  lived 
and  accumulate  in  institutions,  so  that  they  comprise 
about  40  per  cent,  of  the  inmates.  The  forming  of  proper 
mental  habits  is  to  a  considerable  extent  possible,  and 
may  avert  such  types  of  precocious  mental  breakdown. 
One  must  not  permit  worries,  cares,  anxieties,  and  desires 
to  become  obsessions  by  brooding  over  them,  but  use  will 
and  self-control  in  banishing  them  by  directing  the 
thoughts  into  other  channels,  by  work,  by  interest  in 
others,  and  by  confessing  one's  troubles  to  a  sympathetic 
friend  which  will  often  clear  the  mental  atmosphere  and 
aid  in  establishing  mental  equilibrium.  Then,  again, 
oversensitiveness  to  fancied  slights  and  offense  may  lead 
in  the  susceptible  to  the  actual  delusions  of  the  insane  that 
the  subject  is  being  persecuted  by  imaginary  persons,  or 
the  constant  mental  warfare  with  the  obsessing  thoughts  or 
desires  may  result  in  perversions  of  the  senses  so  that  the 
patient  hears  imaginary  voices  or  sees  imaginary  objects 
(hallucinations). 

While  the  intellect,  will,  and  memory  are  so  impaired  in 
dementia  that  the  patient's  mental  condition  is  patent  to 
all,  yet  in  another  less  common  form  of  insanity,  paranoia, 
the  subject  may  show  no  mental  deterioration.  These 
are  the  persons  who  commit  crimes,  while  their  apparent 
mental  acuteness  deceives  juries,  and  they  escape  com- 
mitment to  institutions  for  the  criminal  insane  notwith- 
standing the  absolute  certainty  as  to  diagnosis  in  the 


PREVENTION    OF    NERVOUS    AND    MENTAL    DISEASES      257 

opinion  of  unbiased  experts.  The  latter  are  rarely  called 
in  such  cases,  however.  One  notable  example  is  that  of 
a  paranoiac  who  murdered  a  leading  professional  man  of 
this  country  and,  constantly  trying  to  escape  incarcer- 
ation for  years,  has  recently  succeeded — owing  to  the 
influence  of  money.  In  every  community  there  are 
lamentable  instances  of  miscarriage  of  justice  in  the  case  of 
criminal  paranoiacs.  They  are  frequent  litigants  and 
difficult  to  convict.  The  paranoiac  imagines  he  is  being 
persecuted  and  deprived  of  his  property,  business,  or  pro- 
fessional rights,  or  that  some  one  is  alienating  the  affections 
of  his  wife  or  fiancee.  It  is  for  this  reason  that  he  is 
dangerous  and  is  apt  to  make  sudden  murderous  assaults 
upon  his  fancied  enemies.  Paranoiacs  are  often  able  to 
attend  to  their  business,  talk  quietly  and  well  upon  current 
topics,  and  thus  commonly  delude  the  casual  observer. 
They  are,  however,  born  with  a  defective  nervous  anatomy 
and  show  faulty  development  and  peculiarities  in  child- 
hood, and  though  bright  in  school,  are  self-conceited,  sus- 
picious, and  morbid. 

Later  the  paranoiac  discovers  that  he  is  an  exalted  char- 
acter— of  noble  birth,  a  prophet,  or  Christ.  In  killing 
prominent  persons  the  paranoiac  believes  himself  a  public 
benefactor.  Being  impressionable,  paranoiacs  are  ready 
tools  for  anarchists  and  unprincipled  men. 

There  is  a  large  class  of  cases  comprising  the  type  of 
manic-depressive  insanity.  This  is  peculiarly  an  inherit- 
ance which  curses  many  families.  In  the  form  of  mania 
the  patient  may  be  noisy,  restless,  and  violent,  destroying 
furniture.  But  often  in  this  phase  he  is  only  in  an  excited 
and  pleasurable  state  of  mind.  He  thinks  he  is  rich  and 
gives  money  away  in  an  absurd  fashion,  talks  constantly, 
makes  friends  without  discrimination,  and  sleeps  poorly. 
In  the  depressive  form,  or  melancholia,  there  is  the  opposite 

17 


258  THE    PREVENTION    OF   DISEASE 

condition.  Here  the  patient  may  sit  motionless  and 
brooding  in  gloom  and  despondency.  He  imagines  he  is 
worthless  or  has  committed  the  unpardonable  crime;  or 
there  may  be  signs  of  deep  distress,  restlessness,  the  subject 
moving  back  and  forth  and  wringing  his  hands  and  moan- 
ing. The  tendency  to  suicide  is  common.  Sometimes 
periods  of  exaltation  alternate  with  those  of  depression 
after  an  intervening  period  of  normality  (circular  insanity). 
Victims  of  the  manic-depressive  insanity  tend  to  recover  in 
a  variable  time — from  weeks  to  a  year  or  so.  Finally, 
there  is  the  senile  dementia,  in  which  degenerative  changes 
occur  in  the  brain  cells  and  narrowing  of  the  blood-vessels 
in  the  brain  as  a  part  of  old  age. 

Treatment  of  Insanity. — The  laity  have  extraordinary 
ideas  about  the  insane.  They  think  that  they  may  be 
argued  out  of  delusions,  depression,  etc.  It  is  useless  to 
argue  and  combat  imaginary  fixed  ideas  or  delusions,  and 
may  cause  the  patient  to  become  violent.  In  a  general 
way  the  insane  should  be  treated  like  anybody  else,  so  far 
as  is  compatible  with  safety  regarding  themselves  and 
others.  Individuals  who  show  great  depression  should, 
however,  be  carefully  watched  to  prevent  them  from  com- 
mitting suicide,  and  those  laboring  under  the  delusion  that 
they  are  being  persecuted  or  wronged  should  be  put  under 
restraint  lest  they  become  guilty  of  homicide. 

The  sanatorium  or  hospital  is  the  only  place  for  persons 
with  disordered  minds,  as  the  chances  of  recovery  are  much 
better  away  from  their  ordinary  environment,  and  they  are 
thus  protected  from  doing  violence  to  themselves  or  others. 

There  are  probably  250,000  insane  people  in  the  United 
States  today,  and,  including  the  feeble-minded,  epileptics, 
and  mental  defectives,  there  are  some  750,000  patients 
afflicted  with  mental  defects  and  disease  who  should  be 
in  institutions  in  this  country  (Mullan).  A  large  percent- 


PREVENTION    OF    NERVOUS   AND    MENTAL    DISEASES      259 

age  of  these  cases  might  be  prevented  if  the  various  causes 
enumerated  were  removed  and  if  proper  living  and  mental 
and  physical  training  were  taught  and  practised. 

There  is  great  interest  in  this  subject  at  present,  and 
State  societies  for  mental  hygiene  are  being  established  to 
protect  the  mental  health  of  the  public,  to  study  and  spread 
abroad  knowledge  of  the  causes,  prevention,  and  treatment 
of  mental  disorders,  and  to  better  the  conditions  of  the 
mentally  defective.  We  have  made  a  similar  brief  attempt 
in  the  foregoing  pages  in  reference  to  individual  prevention 
of  mental  diseases. 


CHAPTER  XIV 

THE  PREVENTION  OF  DISEASES  OF  DIGESTION 

Constipation,  Ulcer,  Gastritis,  Gall-stones,  Appendicitis,  Stone  in 
the  Kidney,  Nervous  Indigestion,  Visceroptosis 

CONSTIPATION 

CONSTIPATION  is  the  most  common  and  radical  diges- 
tive disorder.  It  is  impossible  to  say  precisely  how  much 
harm  may  be  accomplished  by  habitual  constipation,  but 
a  large  part  of  known  diseases  has  been  attributed  by 
authorities  to  it.  We  do  know  positively  that  mental 
depression,  physical  weakness  and  loss  of  energy,  headache, 
foul  tongue,  taste,  and  breath  are  often  immediate  results 
of  constipation.  Also  that  inflammation  of  the  bowels, 
diarrhea,  and  piles  result  from  long-continued  stagnation 
of  the  bowel  contents. 

Many  of  the  common  abdominal  diseases,  as  gall- 
stones, appendicitis,  etc.,  are  thought  to  originate  in 
chronic  constipation  by  leading  medical  authorities,  while 
from  constant  absorption  of  poisons  due  to  bacterial 
growth  or  putrefaction  of  delayed  intestinal  contents  all 
kinds  of  constitutional  diseases  may  arise.  The  chronic 
joint  troubles  known  as  chronic  rheumatism  or  rheumatic 
gout,  and  even  hardening  of  arteries  and  premature  old 
age,  are  commonly  believed  by  noted  physicians  to  be 
caused  by  chronic  constipation.  It  is  an  unfortunate  fact 
that  we  are  continually  taking  one-sided  views  of  all 
sorts  of  matters,  so  that  each  specialist,  medical  or  other- 

260 


CONSTIPATION  261 

wise,  is  apt  to  exaggerate  his  own  specialty  and  attribute 
to  it  all  possible  effects,  to  the  exclusion  of  all  others. 

In  chronic  constipation  it  is  the  colon  or  large  intestine 
which  is  at  fault,  and  the  taking  of  buttermilk  has  been 
much  in  vogue,  with  the  idea,  originated  by  Metchnikoff, 
that  its  sour-milk  germs  (lactobacilli)  would  destroy  the 
germs  in  the  bowels  which  were  thought  to  bring  about  the 
changes  in  old  age.  Osier  thus  characterizes  the  fad,  which 
is  now  waning,  as  follows,  "Captivated  by  the  theories 
of  Metchnikoff,  we  have  been  for  some  years  on  the  crest 
of  a  colonic  wave,  and  intestinal  toxemia  (poisoning)  has 
been  held  responsible  for  many  of  the  worst  of  the  ills  that 
flesh  is  heir  to,  more  particularly  arteriosclerosis  and  old 
age.  The  seniles  and  preseniles  of  two  continents  have 
been  taking  sour  milk  and  lactobacillary  compounds,  to 
the  great  benefit  of  the  manufacturing  chemists.  But  the 
fad  is  passing,  not,  as  I  hope,  to  be  replaced  by  one  even 
more  serious,  in  which  operation  is  advised  for  every  case 
of  intestinal  stasis  (stagnation)." 

Without  going  into  further  discussion  as  to  the  possi- 
bilities of  remote  harm  from  constipation,  it  seems  reason- 
able to  believe  that  there  is  no  other  disorder  which  is  so 
generally  preventable  and  at  the  same  time  so  common 
and  so  likely  to  be  provocative  of  serious  local  and  remote 
diseases.  By  constipation  is  meant  retention  of  the  intes- 
tinal contents.  This  may  be  due  either  to  infrequent 
action  of  the  bowels  or  to  insufficient  action;  that  is,  the 
bowels  may  move  daily,  but  not  sufficiently,  so  that 
material  may  remain  for  months  in  the  intestines  while  a 
part  of  the  contents  is  passing  through  or  around  that  left 
behind.  The  natural  action  occurs  owing  to  the  contrac- 
tions and  secretions  of  the  bowels. 

In  constipation  one  or  both  are  deficient.  The  contrac- 
tions may  fail  for  lack  of  the  stimulus  of  sufficient  coarse 


262  THE    PREVENTION   OF   DISEASE 

residue  and  too  good  digestion,  or  sometimes  from  too 
much  residue  in  overeating.  In  many  cases  too  little  water 
is  taken.  Constipation  is  growing  more  common  because 
of  the  increase  of  sedentary  lives  in  cities,  and  because  we 
eat  too  little  coarse  food,  such  as  is  still  used  by  the  peas- 
antry of  many  countries. 

The  constipating  foods  are  the  digestible  foods  which 
leave  little  residue  in  the  bowels.  Thus,  meat,  fish,  and 
eggs  are  notably  constipating.  Among  other  causes  of 
constipation  is  failure  in  attending  to  nature's  needs  at  a 
regular  time  each  day.  The  school  girl  is  too  hurried  or 
modest  to  make  her  wants  known ;  the  business  man  is  too 
busy  to  attend  to  such  a  trifling  matter  as  nature's  most 
imperative  requirement,  he  must  catch  a  train  or  perform 
some  other  important  act.  Persons  may  be  so  interested 
in  reading  while  in  the  closet  that  the  bowels  become  in- 
sensitive. 

Frequently  the  taking  of  powerful  pills  establishes  con- 
stipation as  a  habit,  because  the  intestines  come  to  rely 
on  unnatural  stimulation. 

In  the  milder  forms  of  constipation  simple  measures 
may  remedy  the  trouble.  Thus,  drinking  a  glass  of  hot 
or  cold  water  containing  a  pinch  of  salt  on  rising  and  at 
bedtime,  taking  exercise  on  horseback  ("the  outside  of  a 
horse  is  the  best  thing  for  the  inside  of  a  man"),  in  tennis, 
swimming,  baseball,  golf,  and  eating  stewed  or  raw  fruit  at 
each  meal  may  be  sufficient.  Cooked  fruit  is  more  di- 
gestible, as  apple-sauce,  baked  apples,  stewed  prunes.  An 
attempt  should  be  made  at  a  regular  hour  each  day,  and 
no  alarm  need  be  felt  if  for  two  or  three  days  there  is  no 
bowel  movement  after  beginning  treatment. 

Proper  diet  will  cure  most  cases  of  constipation.  This 
treatment  depends  upon  the  fact  that  certain  articles  of 
food  tend  to  overcome  constipation  in  different  ways. 


CONSTIPATION  263 

Fruits  and  some  vegetables  contain  cathartic  principles, 
and  other  vegetables  act  chiefly  because  they  leave  a  coarse 
residue  to  stimulate  the  bowels.  Among  the  fruits  and 
vegetables  containing  cathartic  principles  may  be  included 
oranges,  grapefruit,  apples,  grapes,  peaches,  pears,  prunes, 
melons,  tomatoes,  cucumbers,  onions,  beets,  carrots,  pota- 
toes, and  spinach;  while  turnips  and  squash,  Brussel 
sprouts,  string  beans,  green  peas,  and  oyster  plant  stimu- 
late the  bowels  by  their  residue.  In  addition,  acids  are 
laxative,  so  that  pickles,  vinegar,  and  acid  fruits  and 
buttermilk  act  through  their  acidity.  Oils,  as  in  salad, 
lubricate  the  contents  of  the  bowels  and  are  laxative,  to- 
gether with  butter,  cream,  and  bacon.  Coarse  bread 
containing  the  hulls  of  grain  is  perhaps  the  most  effective 
laxative  in  stimulating  the  coats  of  the  bowels. 

If  a  person  can  eat  six  slices  of  rye,  whole  wheat,  graham, 
or  "brown"  bread  daily,  that  in  itself  is  often  sufficient  to 
cure  constipation. 

The  constipating  articles  of  food  include  milk,  eggs, 
cheese,  meat,  fish,  tea  (tannin),  cocoa,  chocolate,  red  wine, 
macaroni,  spaghetti,  etc.  It  is  not  possible  to  eliminate 
these  wholly  from  the  diet,  but  they  should  be  eaten  in 
moderation,  while  there  should  be  a  corresponding  increase 
in  the  amount  of  coarse  bread,  fruit,  and  vegetables. 
Sweets  are  also  laxative. 

We  may  give  a  sample  diet  list  as  follows.  It  is  not 
intended  that  a  person  should  eat  every  article  included 
under  each  meal,  but  he  can  vary  his  diet  according  to  the 
dishes  recommended. 

On  rising,  a  glass  of  cold  or  hot  water,  according  to  pref- 
erence, containing  a  pinch  of  salt. 


264  THE   PREVENTION    OF   DISEASE 

Breakfast 

Oatmeal  with  syrup  or  cream  and  sugar,  one  or  two  slices 
of  graham,  rye,  wheat  bread,  corn  bread,  or  Boston 
brown  bread.  Cracked  wheat,  hominy  grits,  or  graham 
meal  may  be  used  in  place  of  oatmeal. 

Fruit  raw  or  cooked,  or  marmalade,  or  honey.  Eggs 
with  bacon  or  omelet  with  apple-sauce  (which  is  excellent). 
Coffee,  cream,  and  sugar. 

Luncheon 

Fish,  as  mackerel,  salmon,  halibut,  herring,  or  sardines. 
One  of  the  coarse  breads,  as  at  breakfast,  or  gingerbread. 
Two  green  vegetables  or  salad.  Jam  or  marmalade. 
Fruit,  as  stewed  apples,  figs,  or  apricots,  etc.  Cider, 
lemonade,  or  weak  Oolong  tea  with  cream  and  sugar,  or  a 
glass  or  two  of  buttermilk. 

Dinner 

Thick  or  thin  vegetable  soups.  Green  vegetables  and 
potatoes,  fish  or  meat,  and  salad  and  pickles.  Two  slices 
of  coarse  bread.  Desserts  of  fruit  or  puddings  of  coarse 
meals,  as  Indian  meal,  or  fruit  puddings,  as  apple  Char- 
lotte, brown  Betty,  etc. 

At  bedtime  a  glass  of  buttermilk,  or  figs,  seedless 
raisins,  or  stewed  prunes. 

The  only  objection  to  this  diet  is  that  some  persons  are 
unable  to  take  it  because  the  coarse  food  gives  them  flatu- 
lence and  pain  and  the  acid  fruits  occasion  heart-burn. 
Then,  again,  if  an  individual  is  traveling  or  not  living  at 
home  it  may  be  impossible  for  him  to  obtain  such  a  diet. 
In  these  cases  the  patient  should  take  a  diet  as  near  that 
described  as  he  can  secure  or  digest,  and,  in  addition,  one 
of  the  remedies  which  1  am  about  to  recommend.  Heart- 


CONSTIPATION  265 

burn  from  acid  may  be  relieved  by  Husband's  magnesia, 
cooking  soda,  or  a  few  soda-mints. 

While  there  is  a  well-founded  popular  prejudice  against 
the  taking  of  physics  for  habitual  constipation,  in  the  case 
of  powerful  drugs  in  pills,  there  is  no  reason  why  the 
active  laxative  principles  of  vegetables  should  be  more 
harmful  than  the  eating  of  the  vegetables  themselves. 

This  is  particularly  true  with  certain  drugs  which  act 
more  to  tone  up  the  muscular  coat  of  the  bowel  in  atonic 
(lack  of  tone)  conditions  than  to  irritate  the  bowels. 
Such  drugs  may  be  rightly  looked  upon  in  the  light  of  in- 
testinal tonics,  and  they  may  be  used  daily  for  years 
without  increasing  the  dose,  and  often  prove  effective  in 
smaller  dose  as  time  goes  on.  Such  a  drug  is  cascara  sa- 
grada,  and  the  writer  has  found  the  aromatic  fluidextract 
of  cascara  sagrada,  made  by  Sharpe  and  Dohme,  the  most 
reliable  preparation.  The  dose  is  half  a  teaspoonful  to  a 
teaspoonful  taken  at  bedtime  without  water.  Some  per- 
sons find  that  a  teaspoonful,  more  or  less,  of  one  of  the 
common  salts  (Epsom,  Glaubers,  or  artificial  Carlsbad) 
each  morning  on  rising  in  a  whole  glass  of  hot  or  cold 
water  is  effective. 

Or  one  of  the  laxative  mineral  waters,  as  Hunyadi 
Janos,  Pluto,  Congress,  Hathorn,  Crab,  Carlsbad,  Apenta, 
Marienbad,  Kissingen,  Friedrichshall,  Condal,  Caribana, 
Rakoczy,  etc.,  taken  on  rising  in  hot  water,  may  be  used. 

It  often  happens  that  the  effect  of  these  salines  wears 
away  in  time  and  one  must  change  to  another.  Recently 
the  use  of  agar-agar,  obtained  from  Japanese  seaweed, 
has  become  deservedly  popular.  It  may  be  used  daily 
without  harm,  as  it  passes  through  the  bowel  unchanged, 
but  in  so  doing  absorbs  much  water  and  swells  and  acts  by 
increasing  the  bulk  of  the  intestinal  contents.  The  writer 
has  found  that  a  mixture  of  agar-agar,  cut  in  half-inch 


266  THE   PREVENTION    OF   DISEASE 

lengths  and  mixed  with  an  equal  amount  of  sterilized  bran 
(sold  by  grocers  in  tight  packages  for  laxative  use),  is 
most  efficient  when  taken  with  a  little  salt  and  mixed  with 
hot  water  like  mush  or  more  like  a  bran-mash  for  equine 
use.  Two  or  more  tablespoonfuls  of  each  are  thus  eaten 
at  bedtime  or  breakfast  with  sugar  and  cream.  The 
mixture  usually  causes  large  normal,  formed  movements. 
In  many  persons  the  agar-agar  alone  will  suffice  taken  in 
the  same  way.  It  may  be  bought  by  the  pound  of  drug- 
gists, but  the  finely  powdered  is  useless.  Another  service- 
able and  harmless  remedy  is  paraffin  oil  or  albolene.  This 
is  sold  by  druggists,  flavored  for  internal  use,  under  the 
name  aromatic  paraffin  oil.  It  is  practically  a  liquid 
vaselin  and  passes  through  the  bowels  unchanged,  lubri- 
cating their  contents  and  thus  facilitating  expulsion  of 
them.  X 

A  tablespoonful,  more  or  less,  may  be  taken  thrice  daily, 
or  a  third  to  half  a  glass  at  night.  In  some  persons  the 
remedy  causes  griping  and  discomfort,  but  in  many  it 
forms  an  excellent  remedy.  I  have  found  either  cascara 
sagrada,  one  of  the  salines,  or  agar-agar  and  bran  the 
most  valuable  remedies  in  habitual  constipation. 

Sulphur  is  useful  in  teaspoonful  doses  at  night  in  cases 
of  hemorrhoids  or  piles.  Senna  is  a  serviceable  drug  in 
chronic  constipation.  From  ten  to  twenty-five  leaves 
may  be  chewed  at  night,  or  two  tablespoonfuls  of  senna 
leaves  are  stewed  with  three  dozen  prunes,  the  leaves  being 
temporarily  placed  in  a  cheese-cloth  bag  in  the  stew,  as  it 
is  not  necessary  to  eat  them. 

The  dose  is  ten  prunes  with  their  juice  one  or  twice 
daily,  and  after  a  time  the  prunes  may  be  taken  alone  by 
gradually  cutting  out  the  senna.  The  fig  syrup  given 
children  for  occasional  constipation  is,  in  reality,  a  prepa- 
ration of  senna. 


CONSTIPATION  267 

Thin  olive  oil  (grown  on  the  hills)  may  be  of  worth  in 
combating  chronic  constipation,  but,  like  albolene,  causes 
griping  and  flatulence  in  some  individuals. 

A  tablespoonf ul  should  be  taken  thrice  daily  after  meals, 
but  it  is  wise  to  begin  with  but  a  teaspoonf  ul  and  gradually 
increase  the  dose. 

Exercise  is  useful  in  almost  all  cases  of  habitual  constipa- 
tion, and  it  not  infrequently  happens  that  persons  find  con- 
stipation a  thing  of  the  past  during  vacation  while  camping 
and  exercising  outdoors. 

Outdoor  exercise  and  games  are  always  best  for  young 
persons,  as  baseball,  tennis,  swimming,  and  horseback 
riding.  In  middle-aged  and  elderly  individuals  golf  is  one 
of  the  most  satisfactory  exercises,  since  violent  exertion  is 
contraindicated.  Walking,  though  good  for  the  general 
health,  is  rarely  effective  in  overcoming  habitual  constipa- 
tion. 

Gymnasium  and  home  exercises  are  of  advantage  when 
outdoor  exercise  or  games  are  not  practical.  I  have  taken 
the  following  exercises  from  Gant's  work  on  "Constipa- 
tion." They  should  be  practised,  one  after  the  other,  for 
fifteen  to  thirty  minutes  once  daily,  "and,  as  a  rule,  if 
persisted  in  they  become  a  habit,  and  the  exercise  is  looked 
forward  to  with  pleasure  (Bettmann)": 

(1)  Stand  erect  with  the  legs  together,  and  slowly  bend 
the  upper  part  of  the  body  to  the  left  as  far  as  possible, 
and  then  to  the  right  in  the  same  manner. 

(2)  Assume  the  erect  posture  and  rotate  or  turn  the 
body  upon  the  hip. 

(3)  Take  the  same  position,  and,  without  bending  the 
knees,  slowly  lean  forward  and  downward  until  the  tips 
of  the  fingers  touch  the  floor  in  front  of  the  toes. 

(4)  Lie  flat  upon  a  firm  bed,  table,  or  couch,  with  the  legs 
held  rigidly  together,  and  raise  the  body  until  it  is  at  a 


268  THE    PREVENTION    OF   DISEASE 

right  angle  with  the  limbs.     (This  is  accomplished  more 
readily  if  the  toes  are  held  down  by  some  object.) 

(5)  Reverse  the  procedure  by  raising  the  stiffened  limbs 
until  they  are  at  a  right  angle  to  the  body. 

(6)  While  still  in  the  recumbent  posture  bend  the  knees 
and  draw  the  thighs  closely  up  against  the  abdomen. 

(7)  Kneel  upon  the  floor  and,  with  the  hips  fixed,  bend 
the  body  in  succession  forward,  backward,  from  side  to 
side,  and  then  rotate  as  far  as  possible  first  in  one  direction 
and  then  in  the  other. 

(8)  Standing  erect,  with  hands  crossed  behind  or  ex- 
tended  fully  above   the   head,    quickly  change    to   the 
squatting  posture. 

(9)  Lean  slantingly  forward  and  repeatedly  draw  up  the 
abdominal  muscles,  and  then  relax,  taking  deep  breaths, 
to  exercise  the  diaphragm  and  the  abdominal  muscles. 

(10)  Extend  both  arms  at  a  right  angle  with  the  body 
so  as  to  form  a  straight  horizontal  line,  and,  with  the  arms 
in  this  position,  walk  six  or  eight  times,  on  tiptoes,  from 
one  end  of  the  room  to  the  other. 

Abdominal  massage  may  be  beneficial  in  some  cases, 
but  as  a  rule  is  not  at  all  necessary,  except  in  much  weak- 
ened women,  when  it  should  be  given  for  fifteen  minutes 
before  rising;  or  a  cannon  ball,  weighing  about  5  pounds, 
may  be  rolled  about  over  the  abdomen  for  this  time. 
Injections  of  water  into  the  rectum  generally  lose  their 
effect  in  time  and  are  awkward  to  take.  The  fad  of 
injecting  large  amounts  of  water  high  up  in  the  bowel  does 
harm  if  persisted  in  for  any  time,  as  the  bowels  become  too 
distended. 

Constipation  is  more  common  in  brunettes.  It  may 
itself  be  caused  by  many  diseases  in  which  there  is  general 
lack  of  tone.  It  is  exceedingly  common  in  anemia  and 
may,  indeed,  lead  to  impoverishment  of  the  blood,  so  we 


CONSTIPATION  269 

have  a  vicious  circle  established.  Then  constipation  may 
be  due  to  faulty  development  of  the  intestines  which  is 
common  in  certain  builds  (see  page  276),  so  that  kinking 
and  partial  obstruction  occurs  at  certain  points  in  the 
course  of  the  large  intestine.  For  this  reason  no  case  of 
chronic  constipation  of  any  intensity  should  be  allowed  to 
continue  without  recourse  to  examination  with  the  x-rays, 
by  which  means  the  whole  course  of  the  large  bowel  may 
be  readily  outlined  and  the  rate  of  progress  of  the  intestinal 
contents  precisely  estimated.  In  chronic  constipation,  in 
which  there  is  almost  obstruction,  the  patient's  skin  is 
very  sallow  and  bronzed,  he  becomes  greatly  emaciated 
and  suffers  from  weakness,  headache,  and  digestive  dis- 
turbances. In  some  of  these  cases  operation  will  yield 
most  remarkably  favorable  results. 

There  is  a  form  of  constipation  (spasmodic)  common  in 
nervous  women  in  which  the  bowel  becomes  contracted 
into  a  cord,  and  this  leads  to  attacks  of  colic;  the  move- 
ment are  ribbon-like  or  occur  as  small,  hard,  round 
pellets,  and  at  times  much  mucus  or  slime  may  be  passed 
from  the  bowels. 

These  cases  require  special  treatment  by  a  physician. 

Constipation  in  Children. — The  feeding  of  pasteurized 
or  boiled  milk  to  infants  may  lead  to  constipation,  but 
unless  certified  milk  can  be  fed,  and  in  any  case  in  hot 
weather,  it  is  safer  to  give  milk  pasteurized  rather  than  run 
the  risks  of  using  milk  which  may  cause  a  fatal  diarrhea. 
Constipation  is  infinitely  preferable  to  diarrhea  in  an  infant. 
Increasing  the  amount  of  cream  in  infants'  milk  may  cure 
constipation,  but  this  again  is  usually  undesirable  in  babies 
fed  on  cows'  milk,  because  an  increase  of  fat  to  an  extent 
greater  than  3.5  per  cent,  is  apt  to  produce  digestive  dis- 
turbance. 

The  addition  of  malted  milk  or  Mellin's  food  (in  place  of 


270  THE    PREVENTION   OF   DISEASE 

milk-sugar  when  it  is  used)  to  the  bottled  milk  will  often 
act  as  a  sufficient  laxative  to  combat  constipation  in  in- 
fants; or  3  teaspoonfuls  of  malted  milk  in  4  ounces  of 
water  may  be  given  once  daily  in  place  of  a  milk  feed- 
ing. Then  orange-juice,  2  tablespoonfuls  twice  daily,  is 
generally  beneficial  for  infants  and  will  tend  to  overcome 
costiveness.  A  small  piece  of  soap,  molded  in  conical 
shape,  may  be  introduced  into  the  bowel  at  the  regular  time 
at  which  the  movement  should  occur,  or  a  glycerin  sup- 
pository, made  for  infant's  use,  may  be  introduced  once 
daily. 

The  best  internal  remedy  for  constipation  is  Philipps' 
milk  of  magnesia,  in  the  dose  of  1  to  2  teaspoonfuls, 
added  to  one  of  the  bottles  of  milk  once  daily.  When 
olive  oil  works  satisfactorily  it  may  be  given  in  place  of  the 
magnesia,  since  it  is  a  food  as  well  as  medicine.  From 
j  to  2  teaspoonfuls  of  oil  may  be  given  after  the  bottle 
feeding  three  times  daily. 

It  is  best  to  begin  with  not  more  than  \  teaspoonful. 

Instead  of  oil,  Squibb's  liquid  vaselin  may  be  employed 
in  a  dose  of  from  2  teaspoonfuls  to  2  tablespoonfuls  once 
daily.  It  will  be  remembered  that  vaselin  is  not  absorbed 
by  the  patient  and  is  absolutely  harmless,  and  passes 
through  the  bowels  unchanged,  acting  simply  as  a  lubri- 
cant. But  it  is  by  no  means  always  effective  and  may 
cause  nausea  and  gas,  and  discomfort  in  the  bowels. 

Older  children  running  about  may  receive  to  advan- 
tage 2  or  3  teaspoonfuls  of  olive  oil,  after  eating,  thrice 
daily,  and  should  be  given  orange-juice,  baked  apple  or 
stewed  rhubarb,  prunes,  or  other  fruit  daily.  Fifteen  to 
thirty  drops  of  the  aromatic  fluidextract  of  cascara  sagrada, 
recommended  above,  may  be  appropriately  given  to  chil- 
dren each  night  for  chronic  constipation  not  relieved  by 
the  additions  to  diet. 


DIGESTIVE    DISEASES  271 

DIGESTIVE  DISEASES 

Digestive  diseases  are  commonly  divided  into  functional 
and  organic.  In  the  functional  forms  there  are  no  changes 
in  the  anatomy  of  the  stomach  or  intestines,  whereas  in 
the  organic  forms  there  are  marked  changes,  as  in  ulcer  and 
cancer  of  the  stomach.  Ulcer  and  cancer  constitute  the 
serious  organic  stomach  troubles,  but  compose  only  about 
10  per  cent,  of  stomach  diseases  as  a  whole.  The  remain- 
ing nine-tenths  of  stomach  disorders  are  functional.  One- 
third  of  these  are  due  to  general  diseases,  one-third  are 
caused  by  prolapse  of  the  abdominal  organs  associated  with 
inherited  nervous  weakness,  and  classified  roughly  as  ner- 
vous dyspepsia,  while  the  remaining  stomach  troubles 
(20  per  cent,  of  the  whole)  are  secondary  (reflex)  and  the 
result  of  diseases  in  other  parts  of  the  abdomen,  especially 
gall-stones  and  chronic  appendicitis.  In  regard  to  cancer 
of  the  stomach  all  we  can  do  in  the  way  of  prevention  is  to 
treat  ulcer,  because  we  know  that  a  large  percentage  of 
cancers  of  the  stomach  (60  to  70  per  cent.)  are  due  to  the 
chronic  irritation  of  ulcers  (Mayo  clinic).  On  the  other 
hand,  the  proportion  of  ulcers,  considered  as  a  whole,  which 
eventuate  in  cancers  is,  of  course,  very  slight. 

Ulcer  of  the  Stomach. — While  ulcer  should  be  cured  to 
relieve  patients  of  suffering,  the  danger  of  cancer  should  be 
an  added  incentive  to  obtain  a  complete  cure.  Only  about 
24  per  cent,  of  ulcers  are  permanently  cured  by  purely 
medical  means  (Joslin). 

At  the  Mayo  clinic  the  proportion  of  cures  following 
operation  for  ulcer  (stomach  and  duodenum)  after  two 
years  and  longer  in  600  cases  is  reported  to  be  67  per  cent., 
and  96  per  cent,  of  the  patients  were  benefited. 

In  the  prevention  of  ulcer  of  the  stomach  we  are  handi- 
capped because  there  is  as  yet  no  exact  knowledge  as  to 
the  cause  of  ulcer. 


272  THE   PREVENTION   OF   DISEASE 

The  probability  of  infection,  that  is,  the  lodging  of 
germs  in  the  walls  of  the  stomach  or  bowel,  is  now  com- 
monly accepted  (see  page  145). 

The  occurrence  of  anemia  in  young  women  and  possibly 
the  secretion  of  excessive  acid  in  the  stomach  have  a  pre- 
disposing influence.  These  conditions  should  be  combated. 
The  recent  remarkable  experiments  of  Rosenow  appear  to 
point  to  ulcer  as  being  at  times  caused  by  the  germs  found 
in  tonsillitis  (streptococci),  and  therefore  the  removal  of 
diseased  tonsils  may  be  the  means  of  preventing  ulcer  and, 
indirectly,  cancer  of  the  stomach  (see  page  149). 

Gastritis. — The  only  other  organic  disease  of  the  stom- 
ach of  importance  (besides  ulcer  and  cancer)  is  gastritis. 
Any  case  of  chronic  stomach  indigestion  was  called  gastritis 
when  the  author  began  his  medical  studies.  Now  we  know 
that  only  the  most  careful  examination  of  the  stomach 
contents  will  suffice  for  a  diagnosis,  and  the  symptoms  may 
be  latent,  so  that  many  cases  of  gastritis  exist  without 
symptoms.  It  is  far  less  common  than  formerly  thought 
and  taught,  and  in  most  cases  it  is  secondary  to  other  dis- 
eases, as  ulcer  and  cancer  of  the  stomach  or  diseases  of  the 
lungs,  kidneys,  etc. 

Acute  gastritis  with  vomiting  is  common  owing  to  errors 
in  diet,  the  swallowing  of  food  poisons  and  chemicals,  as 
alcohol  and  poisons.  Primary  chronic  gastritis  is  most 
frequently  due  to  abuse  of  alcohol,  tea,  coffee,  and  chewing 
tobacco,  the  taking  of  large  amounts  of  ice- water,  or  to 
overeating  or  the  eating  of  indigestible  food.  It  occurs  in 
some  persons  without  any  apparent  cause. 

Gall-stones,  Appendicitis,  Stone  in  the  Kidney. — So 
much  for  the  organic  diseases  of  the  stomach.  Now  we 
will  consider  the  three  groups  of  functional  indigestion. 
The  first  group,  in  which  the  stomach  is  upset  by  diseases 
in  other  parts  of  the  abdomen,  as  gall-stones,  chronic  ap- 


DIGESTIVE    DISEASES  273 

pendicitis,  stone  in  the  kidney,  and  diseases  of  the  female 
sexual  organs,  we  may  dismiss  in  a  few  words  because  of 
our  ignorance  of  the  cause  of  some  of  these  diseases.  There 
is  no  exact  knowledge  pertaining  to  the  origin  of  appendi- 
citis and  gall-stones.  At  present  it  appears  that  infections 
in  the  mouth  and  throat  may  at  times  be  a  source  of 
these  diseases  (see  page  145),  but  the  causation  of  gall- 
stones and  appendicitis  is  still  a  debatable  question.  Little 
positive  can  be  yet  affirmed.  Being  unaware  of  the  cause 
of  many  ailments,  we  naturally  are  unable  to  prevent  them; 
but  as  90  per  cent,  of  stomach  troubles  are  caused  by  dis- 
eases situated  outside  of  the  stomach,  it  logically  follows 
that  the  most  careful  examination  of  the  whole  body 
should  be  made  in  every  case  of  chronic  indigestion. 

This  statement  is  true  not  only  because  of  the  abdominal 
disorders  which  lead  to  disturbance  of  the  stomach,  but 
also  because  of  the  general  diseases  which  sometimes  give 
rise  to  stomach  trouble  as  their  chief  symptom.  The 
writer  can  think  of  patients  coming  to  him  for  stomach 
trouble  caused  by  eye-strain,  by  a  tumor  of  the  womb,  by 
consumption,  by  Bright's  disease,  by  stone  in  the  kidney, 
by  tuberculosis,  peritonitis,  etc.,  etc.  Many  of  the  stom- 
ach specialists  have  in  the  past  failed  to  make  correct  diag- 
noses because  of  lack  of  knowledge  now  possessed  by  the 
abdominal  surgeon,  and  because  they  relied  overmuch  on 
the  findings  of  analysis  of  the  stomach  contents,  and  took 
too  narrow  a  view  of  the  matter.  One  skilled  and  broadly 
experienced  in  general  medical  work  and  who  keeps  in 
touch  with  the  surgeon  is  the  best  physician  for  the  diag- 
nosis of  stomach  troubles. 

A  leading  Southern  surgeon  tells  the  story  of  a  patient 
with  stomach  trouble  who  went  from  doctor  to  doctor  with- 
out relief,  and  as  no  organic  disease  was  discovered,  the 
general  verdict  was  nervous  dyspepsia.  At  last  the  patient 

18 


Profile  in  normal  person. 


3 

Visceroptosis. 
274 


Profile  in  visceroptosis 


Fig.  8. 


4 
Normal. 


DIGESTIVE    DISEASES  275 

had  a  perfectly  plain  attack  of  appendicitis,  his  appendix 
was  removed,  and  recovery  from  his  digestive  symptoms 
was  expected.  But  before  long  all  the  old  pain  and  trouble 
began,  and  the  original  diagnosis  of  nervous  dyspepsia  was 
again  pronounced  with  added  vigor  and  confidence. 
While  going  the  rounds  of  the  medical  prof  ession  the  patient 
suddenly  developed  symptoms  of  gall-stones,  and  these 
were  removed  by  another  surgeon,  who  thought  he  had  at 
last  performed  a  permanent  cure.  But  in  a  short  time  the 
same  distress  again  appeared,  and  then  the  doctors  knew 
the  patient  was  a  "neuro"  or  nervous  subject.  The  patient 
still  persevered  with  the  profession,  not  driven  to  quackery 
by  his  unfortunate  experiences  as  so  many  are,  and  came 
to  a  doctor  who  suggested  an  z-ray  picture  of  his  kidneys. 
The  finding  of  a  stone  in  the  kidney  was  the  reward,  and  on 
its  removal  the  patient  made  at  last  a  permanent  recovery. 
The  stone  was  present  during  the  whole  period  of  the 
patient's  illness,  and  a  thorough  and  complete  examination 
of  his  case  had  never  been  made,  because  it  is  so  much 
easier  to  use  the  phrase  "nervous,"  which  throws  the  onus 
on  the  patient  and  makes  him  feel  properly  humiliated. 
No  diagnosis  of  chronic  stomach  trouble  is  complete  until 
not  only  a  general  examination  of  the  body  has  been  made, 
including  that  of  the  bowel  contents,  blood,  urine,  and  ex- 
pectoration (if  there  is  any) ,  but  also  until  plates  have  been 


Fig.  8. — 3  shows  the  long,  narrow  chest  and  abdomen  and  the 
narrow  angle  formed  by  the  lower  border  of  the  ribs  at  A,  the  so- 
called  costal  angle;  2  shows  the  flat  back  as  compared  with  the 
profile  of  the  normal  back  in  1.  The  internal  organs — large  in- 
testine, kidneys,  liver — lie  on  this  shelf  at  B,  and  are  not  so  likely  to 
prolapse  as  when  attached  to  a  perpendicular  back,  as  shown  in  1. 
In  4  is  shown  the  normal  broad  chest  and  broad  costal  angle  at  A . 
The  width  of  this  angle  alone  is  sufficient  to  exclude  the  presence  of 
visceroptosis  in  most  cases,  as  seen  in  4  at  A. 


276  THE   PREVENTION    OF   DISEASE 

taken  with  the  x-ray  of  the  abdominal  organs,  and  the 
movements  of  the  stomach  should  be  observed  at  the  time 
of  taking  the  pictures  with  the  x-ray  machine. 

All  this  is  essential  before  pronouncing  the  case  one  of 
"nerves." 

Nervous  Dyspepsia  and  Visceroptosis. — This  brings  us 
at  last  to  the  subject  of  nervous  dyspepsia.  All  persons 
may  be  divided  into  two  classes  for  this  purpose.  There 
are  the  normal,  with  broad  chests  and  well-developed  bodies 
(Fig.  8,  1  and  4),  and  the  others.  The  second  class  have 
long  narrow  chests  and  bellies.  They  are  thin,  often  stoop, 
and  have  projecting  shoulder-blades. 

Their  bellies  are  large  in  proportion  to  the  rest  of  their 
bodies,  and  instead  of  projecting  more  above  the  navel,  the 
belly  is  more  prominent  below  the  navel.  Their  backs  are 
straight  below  the  shoulder-blades,  lacking  the  proper 
curve  in  the  "small  of  the  back"  (Fig.  8,  2). 

A  special  diagnostic  point  is  the  fact  of  the  narrow 
angle  to  be  observed  at  the  upper  part  of  the  belly 
formed  by  the  lower  border  of  the  ribs.  This  is  of 
such  importance  that  there  is  an  instrument  made  for 
determining  the  angle  (Fig.  8,  3).  In  the  normal 
person  this  angle  is  broad  (Fig.  8,  4).  In  children 
we  find  frailness,  lack  of  fat,  slenderness  of  muscle,  and 
lack  of  vigor.  In  the  adult  there  is  a  falling  downward 
of  the  abdominal  organs,  as  the  stomach,  large  intestine, 
liver,  and  kidney.  In  the  child  who  creeps  like  a  quad- 
ruped there  is  little  disturbance,  but  when  it  assumes  the 
erect  posture  digestive  troubles  begin.  There  are  develop- 
mental defects  in  these  patients.  The  attachments  of  the' 
organs  are  long,  lax  or  defective,  the  back  is  straight  (Fig. 
8,  2) ,  and  the  angle  or  shelf  normally  present  in  the  upper 
part  of  the  back  is  absent  and  the  organs  sag  directly 
downward.  The  narrow  chest  (i.  e.,  from  side  to  side) 


DIGESTIVE    DISEASES  277 

gives  less  room  for  the  organs  in  the  upper  part  of  the  belly, 
as  the  kidneys,  liver,  and  stomach,  another  reason  for 
downward  displacement  of  these  organs.  Persons  with 
these  various  abnormalities  of  build  are  said  to  have  viscer- 
optosis  or,  in  other  words,  ptosis,  or  sagging  of  the  ab- 
dominal organs  or  viscera.  In  this  class  of  patients,  which 
one  can  recognize  (even  when  they  are  dressed)  by  their 
build  and  more  certainly  if  one  can  observe  the  angle  of 
the  lower  border  of  the  ribs,  functional  digestive  disorders 
are  to  be  expected. 

These  are  included  in  the  group  of  nervous  dyspepsias. 
There  is  another  division  of  persons  with  visceroptosis 
depending  upon  the  fact  that  they  are  of  normal  build,  but 
owing  to  marked  relaxation  of  the  abdominal  walls  the 
organs  have  sagged  downward  and  become  displaced. 
This  condition  more  often  follows  pregnancy  in  which  there 
is  great  distention  of  the  abdomen  with  stretching  of  the 
walls,  followed  by  sudden  relief  from  pressure  and  muscular 
flabbiness  of  the  abdominal  walls  after  childbirth. 

After  a  long,  debilitating  disease,  especially  typhoid  fever, 
the  same  result  may  occur.  Faulty,  stooping  posture  in 
young  persons  favors  visceroptosis  by  crowding  down  the 
abdominal  organs.  Loss  of  weight  removes  fat  about  the 
abdominal  organs  and  allows  them  to  sag. 

Corsets  compressing  the  upper  part  of  the  abdomen 
tends  to  force  down  the  organs.  Constipation  loads  the 
bowel  with  an  extra  weight  of  contents  which  aids  its  pro- 
lapse. But  in  most  cases  the  faulty  development  of  the 
supports  of  the  abdominal  organs  and  the  build  of  the 
patient  are  the  primary  causes.  Indeed,  the  defective 
build  and  the  defective  nervous  organization  which  accom- 
panies it  are  frequently  hereditary.  About  1  in  every 
4  women  has  defects  in  her  build  and  abdominal  sup- 
ports which  lead  to  visceroptosis.  But  not  all  these  per- 


278  THE   PREVENTION    OF   DISEASE 

sons  become  patients.  About  1  in  every  6  patients  coming 
to  the  stomach  specialist  is  suffering  from  the  effects  of 
visceroptosis,  and  the  disease  is  seven  times  more  frequent 
in  women  than  in  men  (Lockwood). 

The  symptoms  do  not  usually  appear  until  early  adult 
life,  when  the  effects  of  stress  and  strain  become  evident. 
The  sagging  of  the  abdominal  organs  causes  kinks  in  them 
and  so  gives  rise  to  constipation.  The  absence  of  general 
nervous  and  muscular  vigor  favors  loss  of  tone  in  the 
stomach  and  the  most  frequent  form  of  indigestion,  i.  e., 
atonic  (without  tone),  dyspepsia  characterized  by  a  feeling 
of  fulness  and  distention  in  the  stomach,  belching  of  gas  and 
heart-burn,  loss  of  appetite,  nausea,  vomiting,  etc. 

Patients  with  visceroptosis  exhibit  another  common 
symptom,  although  this  may  be  present  in  any  case  where 
there  is  loss  of  tone  in  the  stomach.  If  such  a  one  lies 
down  on  his  back  on  a  bed,  and  the  abdominal  wall  is 
suddenly  pushed  inward  over  the  stomach,  a  splashing 
sound  will  be  elicited.  This  may  occur  in  any  one  im- 
mediately after  drinking,  but  in  persons  with  loss  of  tone 
in  the  walls  cf  the  stomach  it  may  be  heard  at  almost  any 
time  between  meals. 

But  many  persons  with  visceroptosis  do  not  suffer  from 
the  sagging  organs,  and  others  recover  from  their  symp- 
toms while  the  state  of  their  abdominal  organs  remains 
unchanged.  So  that  it  will  be  seen  in  any  given  case  one 
cannot  certainly  say  that  the  faulty  position  of  the  ab- 
dominal organs  is  responsible  for  the  presence  of  symp- 
toms, but  that  the  symptoms  may  result  from  fatigue  due 
to  a  weak  nervous  system.  The  same  symptoms,  as  con- 
stipation and  indigestion,  may  occur  in  persons  free  from 
visceroptosis.  We  can  definitely  affirm,  however,  that 
persons  born  with  visceroptosis  are  pretty  sure  to  be  thin 
and  nervous,  and  that  to  cure  them  not  only  must  the 


DIGESTIVE    DISEASES  279 

abdominal  organs  be  pushed  up  into  place,  but  treatment 
for  weak  nerves  must  also  be  pursued.  In  some  patients 
this  treatment  consists  in  the  wearing  of  the  right  kind  of 
abdominal  belt  and  rest  in  bed,  accompanied  by  a  fatten- 
ing diet,  which  accomplishes  two  ends — first,  the  formation 
of  fat  within  the  abdomen,  which  holds  the  organs  up  in 
place,  and,  second,  the  rest  and  forced  feeding,  which  is 
the  best  method  of  treating  nervous  weakness. 

We  may  define  visceroptosis,  then,  as  a  condition  in  which 
there  are  anatomic  displacements  of  the  abdominal  organs 
combined  with  a  tendency  to  nervous  derangements,  usu- 
ally inherited,  but  sometimes  acquired.  A  large  propor- 
tion of  such  patients  are  subject  to  functional  or  so-called 
nervous  indigestion. 

It  by  no  means  follows  that  nervous  indigestion  is  always 
due  to  visceroptosis,  however,  but  any  causes  tending  to 
lower  the  tone  of  the  nervous  system  are  capable  of  causing 
nervous  dyspepsia. 

Nervous  dyspepsia  is  then  brought  on  by  physical  or 
mental  overwork,  dissipation,  strain  of  any  kind,  as  from 
family  troubles  (sickness  and  death),  an  unhappy  love 
affair,  or  business  difficulties;  certain  debilitating  dis- 
eases predisposed  to  nervous  indigestion,  as  tuberculosis 
or  anemia. 

The  chief  difference  between  functional  and  organic 
diseases  of  the  stomach  lies  in  the  fact  that  the  patient 
suffers  genuine  pain  in  organic  disease,  whereas  in  func- 
tional stomach  trouble  there  may  be  great  discomfort  from 
a  feeling  of  fulness,  distention,  heart-burn,  nausea,  vomit- 
ing, belching  of  gas,  and  bringing  up  of  acid  in  the  throat, 
etc.,  but  not  real  hard  pain  at  any  time.  Then  another 
important  distinction,  which  has  already  been  made,  is 
that  the  presence  of  visceroptosis  is  itself  presumptive  of 
functional  rather  than  organic  disease,  since  in  subjects 


280  THE    PREVENTION   OF   DISEASE 

of  this  habit  one  expects  functional  dyspepsia  to  occur. 
On  the  other  hand,  of  course,  it  does  not  follow  that  a 
person  with  visceroptosis  may  not  have  organic  disease 
of  the  stomach,  but  the  chances  are  that  any  digestive 
disturbance  is  much  more  likely  to  be  functional  than 
organic  in  the  case  of  such  individuals. 

The  prevention  of  nervous  functional  dyspepsia  should 
begin  in  infancy  in  children  who  have  inherited  the  tend- 
ency, as  shown  by  the  build  which  we  have  described 
above.  In  general,  the  same  care  should  be  given  them 
as  we  have  already  recommended  in  another  place  for  the 
progeny  of  nervous  parents  (see  page  247).  A  full  nour- 
ishing diet,  with  plenty  of  cream  and  butter  and  a  healthy 
outdoor  life,  with  sufficient  rest  and  sleep,  are  especially 
desirable.  The  clothing  should  not  hang  from  the  outer 
part  of  the  shoulder,  but  from  straps  coming  over  the 
shoulders  close  to  the  neck  so  as  not  to  make  the 
shoulders  droop.  The  child  should  be  taught  to  stand 
and  sit  erect,  as  in  stooping  the  abdominal  organs  are 
pushed  downward  out'  of  place.  If  the  child  cannot 
be  made  to  stand  erect  in  any  other  way  a  brace 
may  have  to  be  fitted  by  a  doctor.  To  assume  the 
proper  position  the  endeavor  should  be  made  to  stand 
as  if  one  were  attempting  to  be  as  tall  as  possible 
without  raising  the  heels  from  the  ground.  This  brings 
the  head  up  and  back.  The  common  directions  to 
"throw  the  shoulders  back"  are  not  sufficient,  and  do  not 
cause  the  head  to  be  held  erect  nor  the  stomach  to  be  held 
in,  as  is  accomplished  by  the  other  position.  The  drinking 
of  large  amounts  of  water  between  meals  is  detrimental  to 
persons  with  visceroptosis  in  favoring  sagging  of  the 
stomach.  After  any  long,  weakening  illness,  as  typhoid 
fever,  the  patient  should  not  be  permitted  to  get  up  until 
his  normal  weight  has  been  restored,  because  otherwise 


DIGESTIVE    DISEASES  281 

the  abdominal  organs  may  prolapse  from  lack  of  the  ab- 
dominal fat-padding  which  naturally  holds  them  up  in 
place. 

Following  childbirth  it  is  always  advisable  for  women  to 
wear  a  proper  abdominal  belt,  as  the  so-called  Storm 
binder,  in  order  that  they  may  not  suffer  from  sagging  of 
the  stomach  and  other  abdominal  organs  ^vhich  is  so  com- 
mon at  this  time.  When  the  disease  of  visceroptosis  is 
present  in  an  aggravated  form  with  nervous  symptoms, 
emaciation,  and  digestive  disturbances,  such  as  we  have 
already  enumerated,  treatment  of  the  patient  while  up  and 
about  is  so  unsatisfactory  that  no  physician  should  attempt 
it.  In  the  milder  degrees  of  the  trouble  a  good  fitting  belt 
may  be  sufficient,  with  rest  and  drinking  of  a  pint  of  cream 
daily,  but  in  the  severe  forms  only  a  course  of  a  month  or 
six  weeks  in  bed  with  the  rest  treatment  in  a  sanatorium, 
followed  by  the  use  of  a  belt,  will  suffice.  The  question  of 
operation  will  arise  in  cases  in  which  there  is  loss  of  appe- 
tite, vomiting  (sometimes  of  blood),  emaciation,  great 
apathy,  persistent  constipation,  flatulence,  muscular  and 
joint  pains,  and  in  women,  inflammation  of  the  breasts. 
Surgery  is  generally  harmful  to  nervous  persons  and  visce- 
roptosis is  often  relieved  by  the  means  outlined  above.  One 
of  the  chief  reasons  for  resort  to  the  surgeon  is  because  the 
patient  and  physician  have  tired  of  each  other,,  according 
to  one  authority.  There  should  be  very  good  reasons  for 
operating,  and  it  should  be  undertaken  only  after  a  consul- 
tation with  conservative  men  and  after  a  thorough  trial  of 
medical  treatment.  Operation  for  the  cure  of  viscerop- 
tosis is  in  disrepute  with  most  of  the  leading  surgeons, 
unless  there  is  sufficient  displacement  of  the  bowels  to 
produce  actual  obstruction  in  them. 

The  cases  of  nervous  dyspepsia  which  are  not  part  of  a 
visceroptosis  are  practically  due  to  the  same  causes  as 


282  THE    PREVENTION   OF   DISEASE 

nervous  prostration  or  neurasthenia.  The  prevention  of 
this  class  of  cases  is  described  under  Neurasthenia.  While 
some  of  the  causes  may  be  removed,  such  as  mental  and 
physical  overwork,  dissipation,  sexual  abuse  or  excess, 
yet  worry  and  strain  consequent  upon  love  affairs,  family 
or  business  troubles,  or  poverty  are  often  beyond  our 
power  to  aid. 


CHAPTER  XV 

FOOD  POISONING 
INTRODUCTORY    NOTE 

THERE  are  few  fields  of  household  hygiene,  household  sanitation, 
or  household  medicine  in  which  sound  popular  teaching  is  so  im- 
portant as  in  that  which  relates  to  the  sanitation  of  food. 

Right  knowledge  of  this  subject  is  not  only  clouded  by  lack  of 
information,  but  obstructed  by  definite  misinformation  freely  dis- 
pensed by  pseudosanitarians,  who  make  this  subject  their  happy 
hunting-ground.  It  is,  therefore,  a  special  pleasure  to  commend  to 
the  public  so  clear  and  so  well-balanced  a  statement  as  that  which 
follows. 

Milk  is  very  wisely  placed  in  the  forefront  in  discussing  the 
dangers  from  food,  and  the  author's  strong  recommendation  of 
pasteurization  must  be  heartily  endorsed  by  all  familiar  with  the 
subject.  Experience  in  public  health  teaches  me  more  and  more 
clearly  that  no  raw  milk  is  a  safe  food  and  that  pasteurization  by 
the  heating  system  (140°  F.  for  twenty  minutes)  should  be  every- 
where insisted  on.  This  process  destroys  all  disease  germs  without 
altering  the  food  value  of  milk,  except  in  one  respect.  The  pecu- 
liar bodies,  known  as  vitamins,  which  milk  contains,  are  destroyed 
by  heating,  and  infants  fed  on  boiled  and  pasteurized  milk  alone 
may  suffer  from  scurvy  as  a  result.  The  loss  of  vitamins  has  no 
significance,  however,  for  adults,  and  in  the  case  of  infants  the 
remedy  is  to  give  orange- juice  (containing  vitamins)  along  with 
the  pasteurized  milk — not  to  risk  fatal  intestinal  or  other  disorders 
by  feeding  raw  milk. 

In  general,  cookery  is  one  of  the  most  important  of  sanitary 
arts  and  makes  safe  many  of  our  foods  which  would  otherwise  be 
dangerous.  It  must  be  remembered,  however,  that  any  food, 
cooked  or  uncooked,  may  be  infected  by  the  "carrier  in  the  kitchen." 
The  safeguards  against  this  danger  are  the  cultivation  of  habits  of 
personal  cleanliness,  the  regular  washing  of  the  hands  before  handling 
food,  and  the  exclusion  (so  far  as  possible)  of  those  persons  who  are 

283 


284  THE    PREVENTION    OF   DISEASE 

suffering  from  any  symptoms  of  communicable  disease  from  the 
preparation  and  handling  of  food  for  others. 

CHARLES-EDWARD  AMORY  WINSLOW. 

Milk  Poisoning,  Ptomain  Poisoning,  Meat,  Fish,  Fruit,  and  Vege- 
table Poisoning 

MILK  POISONING 

Poisoning  occurs  more  often  from  milk  than  from  any 
other  food.  It  is  a  wonderfully  good  food  for  germs  as 
well  as  for  man,  and  the  germs  not  only  live  in  it,  but  multi- 
ply tremendously.  There  are  always  germs  in  milk,  even 
in  boiled  milk,  unless  it  has  been  boiled  several  days  in 
succession.  Raw  milk  contains  to  the  teaspoonful  from 
5000  bacteria,  in  the  very  cleanest  and  most  expensive 
certified  milk,  to  5,000,000  or  more  bacteria  in  market 
milk.  In  fact,  the  poorer  samples  of  market  milk  contain 
more  germs  than  sewage.  The  germs  are  derived  from  the 
surface  of  the  cow,  from  the  air  and  dust,  from  flies,  from 
the  inside  of  the  cow's  udder,  from  the  inside  of  the  bowel 
(in  manure),  and  from  milkers,  dairy  employees,  milk  uten- 
sils, and  water. 

The  chief  source  of  infant  mortality  in  the  past  has  been 
through  the  diarrheal  diseases  in  summer,  due  almost 
wholly  to  the  contamination  of  milk  with  cow  manure 
which  contains  putrefactive  germs  from  the  cow's  bowels. 
It  has  been  estimated  that  ten  tons  of  manure  have  been 
sold  daily  in  the  milk  of  our  largest  city  in  years  gone  by. 
Conditions  have  enormously  improved.  The  infant 
mortality  has  been  reduced  one-half  or  more  by  the  enforce- 
ment of  sanitary  conditions  and  the  improvement  in  the 
milk  supply.  This  was  notably  so  in  the  case  of  Rochester, 
N.  Y.,  during  Dr.  Goler's  regime.  The  other  disease 
most  frequently  taken  from  the  cow  is  tuberculosis.  This 
chiefly  affects  children,  as  there  is  little  danger  to  adults 


MILK    POISONING  285 

in  drinking  milk,  since  they  are  comparatively  immune  to 
such  infection  by  the  time  they  have  reached  maturity. 
About  15  per  cent,  of  the  deaths  from  tuberculosis  in  infants 
is  due  to  cows'  milk.  Another  frequent  danger  from  milk 
is  infection  with  the  diseases  of  man.  Thus,  there  have 
been  recorded  within  the  past  few  years  outbreaks  of 
thousands  of  cases  of  scarlet  fever,  diphtheria,  typhoid 
fever,  and  tonsillitis  from  drinking  milk. 

Among  253  such  epidemics  (Trask)  there  were  179  cases 
of  typhoid  fever,  51  of  scarlet  fever,  and  23  of  diphtheria. 
Typhoid  fever  is  contracted  from  milk  more  commonly 
than  from  any  other  source  hi  New  York  City  today. 
Within  five  years  in  Boston  there  have  been  some  3000 
cases  of  typhoid  and  scarlet  fevers  and  diphtheria  traced 
to  milk  alone. 

These  diseases  are  conveyed  to  milk  by  the  hands,  by 
the  mouth  in  tasting  milk,  by  bowel  discharges  of  man 
(sewage)  in  the  water  used  to  wash  dairy  utensils,  and  by 
infection  of  milk  in  return  bottles  from  homes  in  which 
disease  exists.  The  particular  danger  which  it  seems  prac- 
tically impossible  to  avert  is  from  "carriers" — apparently 
healthy  dairy  employees  who  carry  about  disease  germs  in 
their  throats  (diphtheria,  tonsillitis),  or  are  passing  them 
continually  from  their  bowels  years  after  recovery  from 
typhoid  fever.  We  have  alluded  in  another  place  (see 
page  148)  to  the  1911  outbreak  of  tonsillitis  or  septic  sore 
throat  in  Boston,  consisting  of  1048  cases  with  48  deaths, 
due  to  infection  of  milk  from  an  apparently  healthy  em- 
ployee at  a  show  farm.  Then  there  was  the  typhoid  epi- 
demic of  several  hundred  cases  the  same  year  in  New  York, 
originating  from  a  healthy  farmer  who  had  *been  dis- 
charging typhoid  germs  from  his  bowels  for  twenty-six 
years  since  his  sickness,  thus  contaminating  his  own  milk 
supply. 


286  THE    PREVENTION   OF   DISEASE 

Now,  in  the  cleanest  milk  it  may  be  impossible  to  elimi- 
nate some  of  these  dangers.  Manure  may  be  usually  kept 
out  of  it  sufficiently  to  prevent  infantile  diarrheas,  but 
accidents  occur.  Disease  of  the  cow's  udder  may  ap- 
pear and  pus  escape  in  milk  long  before  the  most  care- 
ful supervision  detects  it.  A  leading  sanitary  milk 
expert,  Dr.  North,  figures  that  a  ton  of  pus,  blood, 
and  bacteria  from  diseased  udders,  together  with  other 
dirt,  might  be  separated  from  New  York's  weekly  milk 
supply.  Inflammation  of  the  udder  (garget,  mastitis) 
is  a  common  trouble  in  cows.  An  expert  may  find 
one  or  more  cases  in  every  considerable  herd.  The 
germs  (streptococci)  in  milk  from  an  inflamed  udder  may 
also  cause  outbreaks  of  severe  sore  throat  or  tonsillitis 
in  man  just  as  do  the  same  germs  from  the  human  throat 
which  accidentally  contaminate  milk  (see  above).  Cows 
may  be  taken  into  herds  which  are  tuberculous  before 
the  test  can  show  this  condition.  North  estimates  the 
existence  of  5  per  cent,  of  tuberculous  cows  in  tested 
herds  supplying  certified  milk — 20  to  40  per  cent,  of 
cows  have  been  found  tuberculous  in  famous  certi- 
fied herds  (see  page  120).  Finally,  employees  infect  milk 
unknowingly  and  so  produce  thousands  of  cases  of  illness. 
All  these  accidents  being  possible  in  the  best  dairies  and 
actually  occurring,  how  can  they  be  stopped?  By  only 
one  measure,  and  that  is,  cooking  the  milk. 

This  means  pasteurizing  milk,  or  heating  it  to  145°  F.  for 
thirty  minutes,  followed  by  rapid  cooling.  By  this  degree 
and  duration  of  heating  disease  germs  of  all  kinds  are  un- 
questionably destroyed. 

The  proportion  of  germs,  other  than  disease  germs,  which 
are  killed  varies,  and  the  more  germ-laden  the  milk  before 
heating,  the  more  so  is  it  apt  to  be  after  pasteurization. 

In  other  words,  but  a  certain  percentage  of  the  miscel- 


.  MILK    POISONING  287 

laneous  germs  are  killed.  Thus,  in  a  sample  of  milk  con- 
taining 400,000  germs  per  \  teaspoonful  before  pas- 
teurization there  were  23,000  after  its  completion;  while 
a  sample  of  milk  holding  40,000  germs  to  the  |  tea- 
spoonful  before  pasteurization  was  found  to  contain 
3000  afterward.  But  commercial  pasteurization  is  un- 
certain, and  through  carelessness  and  break-downs  in  the 
machinery  the  product  is  often  unsafe.  Moreover,  out- 
breaks of  disease  have  occurred  from  pasteurized  milk 
which  was  infected  by  handling  it  during  the  subsequent 
bottling.  The  only  safe  commercially  pasteurized  milk 
is  that  bottled  at  the  farm  or  dairy  and  then  pasteurized 
in  the  bottle,  as  is  done  at  the  Deerfoot  farm  in  South- 
boro,  Mass.,  and  in  a  few  other  places. 

But  it  is  perfectly  possible  to  secure  a  safe  milk  by  buying 
the  best  to  be  obtained  and  pasteurizing  it  at  home.  I 
find  by  boiling  water  (as  much  as  possible)  in  the  outer 
part  of  a  2-quart  double  boiler,  and  then  removing  it  from 
the  stove  and  placing  a  quart  of  milk  in  the  covered  inner 
part,  that  the  milk  may  be  brought  to  140°  or  145°  F. 
within  ten  minutes  and  retained  at  this  point  for  thirty 
minutes,  with  the  exception  of  a  loss  of  2  degrees  during 
the  last  five  minutes.  The  milk  should  be  kept  during 
this  time  in  a  warm  place  or  covered  with  a  cloth. 

By  the  use  of  a  dairy  thermometer,  sold  by  druggists, 
any  intelligent  person  can  secure  this  result,  and  by  taking 
the  same  quantity  of  milk  and  water  each  day,  after  the 
proper  conditions  have  been  fulfilled,  one  may  repeat  the 
process  indefinitely  without  recourse  to  the  thermometer. 

The  cleanest  milk  is  that  most  suitable  for  pasteurization 
since  the  heating  only  destroys  a  percentage  of  bacteria,  and 
the  poisons  which  the  germs  produce  in  their  growth  are  not 
necessarily  destroyed  by  heat,  although  usually  they  are. 

So  that  one  should  buy  certified  milk  if  it  is  within  one's 


288  THE    PREVENTION    OF   DISEASE 

means,  or  the  best  milk  obtainable,  and  then  pasteurize  it. 
For  pasteurizing  milk  for  babies  the  Freeman  pasteurizer 
is  most  convenient,  as  the  process  is  done  by  simply  filling 
the  nursing  bottles  with  milk  for  the  twenty-four  hours' 
uje,  and  placing  them  in  boiling  water  in  his  machine  after 
it  has  been  removed  from  the  stove.  It  is  just  as  impor- 
tant -that  cream  and  milk  for  making  butter  and  cheese  be 
pasteurized,  as  disease  germs  live  in  these  articles  for 
months.  This  is  not,  however,  generally  done  in  this 
country. 

Ice-cream  is  a  frequent  cause  of  poisoning  when  it  has 
been  stored  for  some  time  before  using.  The  most  enor- 
mous number  of  germs  ever  found  in  (sweet)  milk  products 
exist  in  ice-cream  after  it  has  been  kept  for  some  time,  even 
at  zero  temperatures.  Over  100,000,000  bacteria  to  the 
teaspoonful  is  not  unusual,  as  the  intense  cold  does  not  pre- 
vent the  multiplication  of  bacteria  (in  the  course  of  time). 
The  safeguard  is  to  make  ice-cream  from  fresh  pasteurized 
cream  at  home,  or  to  only  buy  it  from  dealers  upon  whose 
word  one  may  place  dependence.  The  greatest  danger 
lurks  in  the  street  and  small  store  vendor,  who  hawk  un- 
known and  questionable  products  about  among  the  poor 
and  serve  them  broadcast  in  the  popular  "cones."  Ice- 
cream, cream-puffs,  and  custards,  made  from  germ-laden 
milk  or  cream,  are  capable  of  producing  the  most  in- 
tense digestive  disturbances,  with  vomiting,  colic,  diar- 
rhea, and  even  death.  Considering  the  opportunities 
at  every  soda-water  fountain,  and  the  fact  that  fragile 
children  are  the  victims,  it  is  a  marvel  that  the  sick- 
ness and  death  resulting  are  not  greater.  The  Chinese  are 
much  more  advanced  than  ourselves  in  some  respects,  de- 
spite our  boasted  civilization,  for  they  drink  no  uncooked 
milk  or  water,  and  thus  escape  typhoid  fever,  which  is  com- 
mon among  the  Europeans  in  China. 


PTOMAIN    POISONING  289 

The  poisoning  from  eating  ice-cream,  cheese,  cream-puffs, 
frozen  puddings,  and  custards  is  more  often  due  to  milk 
contaminated  with  the  discharges  of  cows  (manure,  etc.), 
and  sometimes  is  derived  from  milk  of  diseased  cows. 

The  germs  inhabiting  the  bowels  of  the  cow  are  those 
chiefly  responsible  (colon  and  allied  bacilli) .  These  organ- 
isms produce  poisons  or  toxins  leading  to  vomiting,  colic, 
diarrhea,  great  prostration,  and  weakness  of  the  heart. 
If  the  milk  were  pasteurized  in  the  beginning  it  is  probable 
that  the  poisons  would  not  be  formed.  Poisoning  from 
ice-cream,  cheese,  and  custard  was  formerly  attributed  by 
its  discoverer,  Dr.  Vaughan,  to  a  special  chemical  sub- 
stance (tyrotoxicon) ,  but  it  is  now  recognized  that  various 
toxins  formed  by  a  variety  of  germs  are  responsible  for  the 
poisoning,  and  usually  not  tyrotoxicon.  The  author  con- 
fesses that  the  milk  question  is  a  special  personal  hobby 
upon  which  he  is  more  or  less  of  an  authority,1  but  the 
enormous  hygienic  importance  of  a  clean  milk  supply  has 
become  more  and  more  evident  with  the  passing  of  the 
years  and  as  a  result  of  experience  and  study. 

PTOMAIN  POISONING 

Ptomain  poisoning  is  a  fashionable  term  covering,  in 
popular  usage,  symptoms  produced  by  almost  any  un- 
known germ  disease  with  abdominal  symptoms.  As  a 
matter  of  fact,  it  does  not  even  mean  food  poisoning, 
for  food  poisoning  means  damage  done  by  a  great  variety 
of  poisons  or  toxins  produced  by  a  corresponding  variety 
of  germs. 

Ptomains  are  certain  definite  chemical  bodies  (basic 
alkaloidal  products)  formed  in  the  putrefaction  of  meat  or 

1  "The  Production  and  Handling  of  Clean  Milk,"  by  Kenelm 
Winslow,  M.  D.,  B.  A.  S.,  M.  D.  V.,  W.  R.  Jenkins  Co.,  New  York, 
third  edition. 
19 


290  THE    PREVENTION    OF   DISEASE 

vegetables.  Only  a  few  instances  are  known  where  food 
poisoning  has  been  due  to  ptomains,  and  no  statement  is 
correct  that  such  has  occurred  without  an  elaborate  con- 
firmative chemical  analysis.  Ordinarily  the  cultivation  of 
gernte  from  an  offending  food  will  explain  the  cause  of 
poisoning,  so  that  the  bacteriologic  rather  than  the  chem- 
ical laboratory  is  the  authority  in  such  cases. 

Ptomain  poisoning  is  an  unfortunate  word,  because, 
while  it  may  please  the  patient  to  be  a  victim  of  such  a 
patrician  disorder,  it  permits  the  doctor  to  make  a  wrong 
diagnosis  without  let  or  hindrance.  In  the  writer's  expe- 
rience, ptomain  poisoning  has  most  often  proved  to  be 
appendicitis,  gall-bladder  trouble,  or  obstruction  of  the 
bowels,  and  the  unnecessary  delay  has  frequently  resulted 
in  the  patient's  death,  which  might  have  been  prevented 
by  timely  surgery.  Ptomain  poisoning  is  a  cloak  of  ignor- 
ance in  the  doctor's  lexicon,  and  must  be  relegated  to  the 
same  category  as  "grip"  and  rheumatism,  which  include 
a  host  of  germ  infections  capable  of  being  recognized.  It 
is  somewhat  difficult  to  be  certain  that  illness  is  due  to 
food  poisoning. 

The  occurrence  of  a  number  of  cases  of  vomiting,  colic, 
and  diarrhea  at  about  the  same  time  in  a  number  of  per- 
sons who  have  eaten  the  same  food  (or  of  nervous  symp- 
toms, as  in  sausage  poisoning,  appearing  some  twenty-four 
to  forty-eight  hours  after  eating  the  food,  and  consisting 
in  dryness  of  the  mouth,  disturbed  vision,  drooping  eyelids, 
loss  of  the  voice,  difficult  swallowing,  etc.)  would  be 
strongly  suggestive  of  food  poisoning.  The  character  of 
the  food  and  the  attending  circumstances,  and,  above  all, 
the  bacteriologic  examination  of  the  suspected  food  will 
positively  determine  the  diagnosis. 

Meat  Poisoning. — Four-fifths  of  all  cases  of  meat  poison- 
ing are  due  to  eating  the  flesh  of  animals  suffering  from  one 


PTOMAIN    POISONING  291 

of  the  germ  diseases,  more  often  cows  killed  because 
of  udder  disease,  blood-poisoning  following  calving,  or 
intestinal  diseases;  and  calves  with  a  form  of  blood- 
poisoning  common  during  the  first  few  weeks  of  life. 

Unfortunately,  the  meat  is  not  altered  in  appearance  in 
such  cases,  nor  is  cooking  by  any  means  a  sure  preventive 
against  poisoning.  Even  poisoning  by  meat  which  has 
decomposed  from  too  long  keeping  is  much  more  fre- 
quent in  the  case  of  animals  diseased  before  slaughter. 
Expert  veterinary  inspection  of  the  various  organs  of 
slaughtered  animals  will  detect  disease  and  prevent  the 
killing  of  sick  animals  for  food,  which  is  most  apt  to  occur 
in  small  towns  where  meat  for  local  use  is  not  properly 
inspected. 

Poisoning  from  meat  which  has  putrefied  from  long 
keeping  is  more  common  in  the  warm  months  and  in  the 
case  of  chopped  meat  or  sausage. 

Putrid  meat  is  usually  recognizable,  if  not  chopped,  by 
softness  and  bad  odor,  especially  about  the  bones  and  fat. 
Boiling,  roasting,  or  frying  lessens  the  danger  from  putrefy- 
ing meat,  but  does  not  absolutely  prevent  it.  Proper  refrig- 
eration in  the  household,  both  before  and  after  cooking 
meat,  is  essential  in  order  to  preserve  it,  otherwise  it  should 
be  eaten  fresh.  It. is  also  advisable  to  clean  refrigerators 
frequently  with  a  hot  solution  of  washing  soda.  The 
poisoning  is  due  to  toxins  or  poisons  produced  by  germs 
which  originate  in  diseased  animals,  or  contaminate  the 
meat  after  slaughter  and  grow  luxuriantly  when  refriger- 
ation is  imperfect. 

It  is  well  known  that  persons  eat  game  when  it  is 
"high"  with  impunity  in  most  cases,  but  such  meat  is 
usually  "hung"  in  cold  weather. 

Pork,  veal,  and  beef  are  the  source  of  meat  poisoning, 
while  mutton  and  lamb  are  almost  always  safe,  partly  be- 


292  THE   PREVENTION    OF   DISEASE 

cause  these  are  free  from  the  diseases  of  bovines.  Pork 
causes  poisoning  because  it  is  imperfectly  preserved  by 
salt  or  smoking,  and  is  often  eaten  insufficiently  cooked 
in  sausage  and  other  forms.  Cold  storage  of  chickens, 
turkey,  and  other  fowl  is  undesirable  because  their  vis- 
cera are  not  removed.  The  enormous  multiplication  of 
germs  at  zero  which  occurs  after  a  considerable  period  is 
exemplified  in  the  case  of  ice-cream  noted  above.  Num- 
bers of  instances  of  poisoning  by  cold-storage  fowl  are 
reported.  The  government  has  issued  a  bulletin  on  the 
matter,  in  which  it  is  pointed  out  that  if  the  internal 
organs  were  removed  before  storage,  and  if  the  fowl  were 
sold  frozen  and  immediately  cooked  and  eaten,  such  food 
would  be  very  desirable.  As  a  matter  of  fact,  the  dealer 
often  allows  the  bird  to  thaw  out  to  improve  its  appearance 
before  sale.  He  may  then  replace  the  fowl  in  cold  stor- 
age and  repeat  the  process  several  times  if  a  sale  is  not 
made. 

Canned  meat  and  canned  vegetables  prepared  by  reli- 
able makers  are  usually  wholesome  because  thoroughly 
cooked,  and  poisoning  has  been  more  frequent  in  the  case 
of  home-made  products.  Usually  if  the  contents  are  bad 
the  ends  of  the  can  will  bulge,  or  the  can  be  "blown,"  and 
putrid  gas  will  escape  when  it  is  opened.  Dishonest 
dealers  are  known  to  have  bought  blown  cans  and  to  have 
let  out  the  gas  and  soldered  them  again.  In  this  case  there 
will  be  two  soldered  holes  in  a  can,  and  such  should  always 
excite  suspicion.  Canned  fish  and  pork  and  beans  have 
produced  reported  cases  of  poisoning.  But  it  is  not  un- 
usual for  the  poisoning  to  follow  carelessness  in  keeping  the 
contents  of  the  can  too  long  after  opening.  Violent  and 
fatal  poisoning  has  originated  from  canned  string  beans, 
which  had  a  rancid  odor  when  opened.  It  is  always  wise 
to  cook  all  canned  vegetables  again,  as  the  cases  of  poison- 


PTOMAIN   POISONING  293 

ing  have  often  been  caused  by  eating  the  product  in  salad 
or  otherwise  without  recooking.  Of  course  "blown" 
cans  should  always  be  rejected,  and  makers  should  be 
required  to  record  the  date  of  canning  on  each  package, 
as  the  danger,  together  with  loss  of  flavor,  increases  with 
age. 

Fish  and  Shell-fish. — There  are  certain  parts  of  fish  in 
certain  countries  and  at  certain  seasons  which  are  poison- 
ous, as  the  roe  of  the  Japanese  fugu,  the  roe  of  the  German 
barbs,  and  the  roe  of  pike  and  meat  of  sturgeon  in  the 
spawning  season.  The  chief  cause  of  poisoning  by  fish 
is  disease  of  the  fish,  or,  more  usually,  that  it  is  kept 
too  long  before  or  after  cooking,  especially  in  warm 
weather. 

It  is  a  good  rule  that  fish  or  shell-fish  should  be  eaten  in 
warm  weather  within  twenty-four  hours  after  they  have 
been  cooked.  I  have  seen  cases  of  poisoning  from  crab 
where  it  was  kept  for  three  days  or  more  and  then  served 
in  some  new  style.  This  keeping  of  shell-fish  is  extremely 
dangerous,  as  bacteria  grow  most  luxuriantly  in  cooked 
fish.  In  the  same  way  poisoning  from  canned  salmon  or 
other  fish  is  more  often  due  to  keeping  the  fish  too  long 
after  opening  the  can.  All  fish  (not  preserved  or  canned) 
should  be  freshly  killed  and  have  firmness  of  flesh,  pink 
gills,  and  bright  eyes.  An  unpleasant  odor  would  nat- 
urally be  sufficient  to  condemn  any  fish. 

Many  persons  have  idiosyncrasies  concerning  fish  and 
shell-fish,  so  that  an  attack  of  nettle-rash  or  hives  will 
follow  their  use.  Crabs  and  lobsters  should  always  be 
boiled  alive  and  eaten  within  twenty-four  hours  afterward, 
even  if  kept  on  ice,  although  trouble  arises  chiefly  in  warm 
weather  and  warm  climates.  When  oysters,  clams,  or 
mussels  live  in  filthy  water  they  become  poisonous  through 
infection  with  germs  from  the  intestinal  discharges  of  man 


294  THE   PREVENTION   OP  DISEASE 

and  other  sources,  so  that  poisoning  may  be  produced  when 
they  are  eaten.  Special  diseases,  as  typhoid  fever  and 
cholera,  are  thus  conveyed  to  man  by  oysters;  and  mussels 
under  such  conditions  may  induce  the  most  fatal  form  of 
food  poisoning  known  owing  to  a  recognized  true  ptomain, 
"mytilotoxin." 

Such  poisoning  may  not  be  prevented  by  thorough 
cooking. 

Vegetable  and  Fruit  Poisoning. — To  go  into  the  details 
of  fungi  poisoning  is  hardly  within  the  province  of  this 
work.  Of  mushrooms  and  toadstools  ten  varieties  are 
poisonous,  one  hundred  and  fifty  are  edible,  and  fifty  are 
of  doubtful  character  among  the  one  thousand  varieties  in 
the  United  States. 

One  should  avoid  eating  mushrooms  which  are  not 
familiar  unless  supplied  from  a  reliable  source.  The  five 
more  common  species  of  edible  mushrooms  in  the  United 
States  are  the  ordinary  field  mushroom  (Agaricus  campes- 
tris),  the  horse  mushroom  (A.  arvensis),  the  shaggy  mane 
(Coprinus  comatus),  the  fairy-ring  (Marasmius  oreades), 
and  the  edible  puffball  (Lycoperdon  cyathiforme).  Such 
popular  tests  concerning  the  safety  of  fungi,  as  their  odor, 
taste,  properties  of  blackening  silver  in  cooking,  etc., 
are  wholly  unreliable.  If  the  novice  wishes  to  gather 
mushrooms  to  eat  he  should  first  receive  field  instruction 
by  an  expert  and  not  trust  wholly  to  book  learning.  The 
swallowing  of  one-sixth  of  a  mushroom  has  caused  death, 
so  that  this  is  no  matter  for  trifling  (see  Bull.  No.  15,  U.  S. 
Dept.  Agric.,  "Some  Edible  and  Poisonous  Fungi"). 

Poisoning  sometimes  occurs  from  potatoes,  surprising 
as  this  may  seem.  Potatoes  belong  to  the  family  (Solana- 
ceae)  of  poisonous  plants  containing  belladonna,  hyoscya- 
mus,  and  stramonium.  However,  it  is  not  always  the 
poison  (solanin)  which  causes  poisoning  in  those  eating 


PTOMAIN    POISONING  295 

potatoes,  but  a  variety  of  toxins  produced  by  a  variety  of 
bacteria  conveyed  to  potatoes  by  handling  them  after 
cooking.  Solanin  is  found  chiefly  under  the  skin  of 
potatoes  and  diminishes  to  nothing  in  the  center  of  the 
tuber.  It  is  only  present  in  harmful  amounts  and  on  rare 
occasions  in  sprouting  potatoes,  in  green  potatoes  grow- 
ing uncovered  by  earth,  and  sometimes  in  young  potatoes. 
The  sprouts,  especially  the  purple  ones,  are  apt  to  contain 
more  of  the  poison.  Poisoning  from  potatoes  is  most  com- 
mon in  warm  weather  and  has  often  happened  in  potatoes 
which  have  been  kept  for  a  day  or  two  after  boiling  and 
then  made  into  salad. 

The  bacteria  were  probably  conveyed  to  the  cooked 
potatoes  by  persons  with  unclean  hands.  While  severe 
vomiting,  colic,  diarrhea,  and  great  weakness  have  been 
caused  by  potato  poisoning  in  large  numbers  of  persons, 
there  has  been  no  fatal  result  in  600  recorded  cases.  To 
prevent  poisoning  green  potatoes  and  all  those  badly 
sprouted  should  be  rejected,  and  other  potatoes  should 
have  all  sprouts  cut  out  and  the  peel  widely  removed  be- 
fore boiling.  There  have  been  no  cases  of  solanin  poison- 
ing from  baked  potatoes.  To  avoid  poisoning  from  cooked 
potatoes  they  should  not  be  kept  any  length  of  tune  after 
boiling,  and  great  cleanliness  of  the  hands  is  necessary  in 
handling  them,  as  germs  grow  and  multiply  enormously  on 
the  potato,  especially  in  warm  weather,  hence  the  reason 
for  potato-salad  poisoning. 

A  mild  poisoning  is  commoner  after  eating  strawberries 
than  any  other  vegetable  food.  Indigestion  and  par- 
ticularly hives  or  nettle-rash  are  the  more  frequent  results. 
Strawberries  lie  on  the  ground  and  come  in  contact  with 
animal  and  sometimes  human  excrement  used  for  fertil- 
izer. 

They  are  eaten  raw,  and  it  is  remarkable  that  more 


296  THE   PREVENTION    OF   DISEASE 

cases  of  severe  poisoning  do  not  occur,  as  the  more  common 
forms  of  food  poisoning  are  due  to  contamination  with 
bacteria  from  the  intestines  of  animals  and  man. 

Metchnikoff  believes  the  eating  of  uncooked  strawber- 
ries a  very  dangerous  matter,  and  goes  so  far  as  to  attribute 
appendicitis  to  the  fruit.  Many  persons  cannot  eat 
strawberries  unless  cooked. 


CHAPTER  XVI 

DISORDERS  OF  NUTRITION 

Beriberi,  Scurvy,  Rickets,  Pellagra,   Obesity,  Diabetes 
BERIBERI 

BERIBERI  is  a  peculiar  disease  resulting  from  disorder 
of  nutrition  owing  to  the  absence  of  certain  unknown  ele- 
ments, or  vitamins,  in  the  food. 

Vitamins  are  substances  existing  in  food  and  essential 
to  growth  and  life.  Certain  disorders,  as  rickets  and 
scurvy  in  children,  scurvy  in  adults,  softening  of  the  bones 
in  pregnant  women,  pellagra,  and  beriberi  are  caused  by 
food  deficient  in  these  substances.  Grains  when  deprived 
of  their  germ  and  outer  coating,  as  wheat,  rice,  barley, 
and  oats,  will  produce  beriberi  in  many  birds  and  animals. 
Vitamins  are  also  destroyed  by  heat  and  by  drying  and 
pickling. 

In  the  case  of  beriberi  experience  and  experiments 
show  that  a  diet  of  rice,  from  which  the  outer  coat  and 
germ  have  been  removed,  is  the  more  common  cause. 
This  is  called  white  rice  or  polished  rice,  and  is  what  we 
ordinarily  use.  In  preparing  white  rice  it  is  steamed,  the 
outer  red  covering  bursts,  the  grain  is  dried,  the  hulls, 
with  germ,  removed,  and  the  rice  is  polished  in  milling. 
Red  rice,  covered  by  its  natural  coats,  will  not  induce 
beriberi.  The  most  interesting  experiments  have  been 
tried,  as  in  the  case  of  the  inmates  of  the  insane  asylum 
at  Singapore,  where  formerly  half  died  of  beriberi.  It  was 

297 


298  THE   PREVENTION    OF   DISEASE 

found  that  the  disease  could  be  produced  or  cured  at  will 
by  feeding  first  polished  rice  and  then  unpolished  rice. 

In  India  a  group  of  men  was  given  polished  white  Siam 
rice  and  developed  beriberi  in  sixty  days,  while  another 
group  living  under  the  same  condition,  but  eating  only 
unpolished  rice,  remained  free  from  the  disease.  But 
when  this  second  group  was  fed  polished  white  rice  beriberi 
developed  within  two  months.  By  exchange  of  clothing 
and  contact  of  the  well  with  the  sick  it  was  shown  that  the 
disease  was  not  infectious  or  contagious. 

The  same  results  have  been  obtained  in  Japan  and  the 
Philippines.  As  many  as  50,000  cases  of  beriberi  arose 
from  the  feeding  of  polished  rice  to  the  Japanese  during 
the  Russian  War,  but  recent  knowledge  of  the  cause  of  the 
disease  has  enabled  the  authorities  to  stamp  it  out.  Osier 
states  that  "there  has  been  no  more  remarkable  triumph 
of  modern  hygiene  than  Takagi's  dietetic  reforms  in  the 
Japanese  navy."  Schaumann  and  others  went  further, 
and  concluded  that  deficiency  in  phosphorus,  as  it  occurs 
in  combination  in  vegetable  or  animal  tissue,  is  the  true 
cause  of  the  disorders  of  nutrition  above  mentioned.  He 
and  others  found  that  rice  which  contained  less  than  0.4 
of  1  per  cent,  of  phosphorus  is  likely  to  produce  beriberi. 
This  conclusion  has  not  been  wholly  accepted,  since  Funk 
claims  to  have  isolated  a  new  substance,  or  true  vitamin, 
the  deficiency  of  which  in  food  is  the  cause  of  beriberi  and 
which  does  not  contain  any  phosphorus.  It  is  unques- 
tionably a  fact  that  the  feeding  of  the  polishings  (germ  and 
bran)  of  rice  will  cure  beriberi,  and  it  seems  probable  that 
food  contains  often  more  than  one  vitamin — some  for 
growth  and  others  for  proper  nutrition.  Thus  in  milk  there 
is  a  vitamin  destroyed  by  heat  or  boiling,  and  pasteurized 
or  boiled  milk  may  cause  scurvy.  But  other  vitamins  in 
milk  survive  heat,  for  in  dried  milk  the  vitamins  are  still 


BERIBERI  299 

present  that  will  cure  beriberi  and  that  are  essential  for 
growth  of  young  animals.  When  there  is  a  deficiency  of 
vitamin  in  food  the  animal  or  man  must  use  up  that  already 
in  the  body,  so  that  some  of  the  tissues  are  damaged.  In 
the  case  of  beriberi  it  is  the  nervous  system  which  is  in- 
volved. At  present  we  must  confess  our  ignorance  of  the 
precise  nature  of  vitamins,  although  evidence  points  to 
either  phosphorus  or  nitrogen  as  being  their  most  likely 
chemical  constituents.  But  we  do  know  that  there  are 
essential  unknown  substances  in  many  foods  which  are 
destroyed  by  removal  of  the  germ  'and  outer  hulls  of 
grains,  or  by  boiling,  heat  in  any  form,  drying,  canning 
and  pickling,  and  that  deficiency  of  these  bodies  in  food 
gives  rise  to  the  diseases  already  enumerated.  That 
while  rice  germs  and  hulls  contain  the  essential  vitamin 
curing  beriberi,  the  vitamin  curing  scurvy  resides  in  fresh 
vegetables  and  fruits,  as  in  fresh  onions,  potatoes,  cab- 
bage, lemons,  limes,  oranges,  apples,  etc. 

White  bread  (deprived  of  the  bran  and  the  embryo  or 
germ  of  wheat)  is  the  most  important  food  from  which 
vitamin  is  removed,  but  all  sorts  of  prepared  foods  in 
which  the  hulls  are  taken  from  grains  or  in  which  heat  is 
used,  as  condensed  and  dried  milk,  dried  eggs,  infant 
and  invalid  foods,  vegetable  and  meat  extracts,  and  canned 
food  or  dried  or  pickled  meat,  are  deficient  in  vitamins  and 
instrumental  in  causing  the  diseases  noted  above.  This 
explains  the  reason  for  beriberi  developing  on  ships  where 
the  crew  live  on  pickled  meat,  dried  potatoes,  rice,  white 
flour  bread,  and  biscuit. 

Beriberi  has  occurred  most  extensively  in  the  Orient,  the 
Chinese  and  Japanese  subsisting  largely  on  a  rice  diet. 
The  disease  has  existed  in  the  Philippines,  India,  and  South 
America,  among  fishermen  in  Europe  and  on  the  New- 
foundland Banks,  on  shipboard,  and  in  this  country  in 


300  THE    PREVENTION    OF   DISEASE 

camps,  mines,  and  asylums.  It  does  not  develop  in  per- 
sons living  on  a  varied  and  mixed  diet  and  in  good  surround- 
ings and  circumstances.  The  lack  of  vitamins  is  only 
felt  hy  those  on  a  restricted  diet,  usually  from  poverty. 
Poor  children  are  stunted  from  being  fed  largely  on 
white  bread.  The  poor  of  the  South  develop  pellagra 
from  a  diet  of  starch  and  sugar.  Babies  fed  on  heated 
milk  have  scurvy  (see  p.  303).  Starch  and  sugar  contain 
no  vitamins.  Fresh  meat,  milk,  eggs,  vegetables,  fruits, 
and  germs  of  grain  abound  in  them. 

Symptoms. — Beriberi  is  from  twenty  days  to  two  to  four 
months  in  developing  and  may  last  many  weeks  or  months. 
The  death-rate  varies  tremendously — from  2  to  50  per  cent. 
The  disease  is  essentially  an  inflammation  of  the  nerves 
throughout  the  body  (polyneuritis).  It  begins  like  a  bad 
head  cold,  with  pains,  swelling,  and  loss  of  sensation  in  the 
limbs.  There  may  be  complete  loss  of  sensation  and  power 
in  the  arms  and  legs,  although  pain,  crawling  sensations, 
and  other  peculiar  feelings  are  common  in  the  limbs.  The 
muscles  are  tender  and  may  waste  away  or  there  may  be 
extreme  dropsy  and  the  whole  body  swells.  The  breath- 
ing becomes  difficult,  the  heart  is  weak,  and  the  pulse 
rapid. 

Prevention  consists  in  change  in  the  diet  depending  upon 
the  cause.  In  most  cases  this  has  been  the  extensive  use 
of  polished  white  rice,  and  the  substitution  of  this  for 
unpolished  rice  is  usually  sufficient. 

The  government  in  the  Philippines  has  forbidden  the  use 
of  polished  rice  among  the  native  troops  and  in  its  institu- 
tions. Thus,  in  the  leper  colony  there  were  309  deaths  in 
1910  from  beriberi,  but  after  changing  the  diet  from  pol- 
ished to  unpolished  rice  not  a  single  case  of  the  disease  de- 
veloped in  the  following  year.  There  is  also  a  duty  of  2\ 
cents  a  kilo  (2.68  pounds)  on  polished  rice  imported  into 


SCURVY  301 

the  Philippines  to  discourage  the  natives  from  using  it. 
Improvement  in  the  general  hygienic  conditions  is  essen- 
tial in  the  treatment  of  beriberi  and  the  use  of  tea  made 
from  rice  hulls  or  polishings,  or  when  a  liberal  diet  is  pos- 
sible this  may  be  given  without  rice.  It  is  a  very  chronic 
disease  and  treatment  in  hospitals  is  advisable.  There  is 
dropsy  or  fluid  in  the  cavities  of  the  chest  and  belly,  so  that 
rest  in  bed  and  saline  cathartics  tend  to  drain  away  the 
fluid,  while  heart  stimulants  are  often  required. 

SCURVY 

Scurvy  has  been  called  "the  calamity  of  sailors."  It 
occurs  in  cities  during  sieges,  in  armies,  almshouses, 
mining  camps,  and  wherever  the  diet  is  deficient  in  fresh 
meat,  milk,  vegetables,  or  fruit.  Certain  other  circum- 
stances predispose  to  scurvy,  as  depressing  conditions, 
homesickness,  fatigue,  and  exposure  to  wet. 

Persons  with  scurvy  become  pale,  weak,  and  emaciated. 
Their  gums  are  soft  and  bleed  easily  and  their  teeth  loosen. 
Purple  spots  are  seen  on  the  skin  which  do  not  disappear  on 
pressure.  The  ankles  swell  and  open  sores  may  develop  on 
the  legs.  Apathy,  headache,  palpitation  or  fluttering  of 
the  heart,  and  occasionally  delirium  occur. 

Scurvy  is  due  to  deficiency  of  some  essential  substances 
in  the  food  or  of  one  of  the  vitamins  (see  page  297). 
Cooking,  heating,  drying,  and  processing  in  the  course  of 
manufacturing  food  products  destroy  the  substances 
which  prevent  scurvy.  Food  which  is  kept  a  long  time 
may  cause  scurvy,  so  it  is  substances  which  exist  in  fresh 
food  that  protect  against  scurvy;  fresh  meat  and  blood  in 
the  Nansen  expedition  prevented  scurvy  in  the  absence  of 
vegetables  and  fruit  juices.  Fresh  onions,  potatoes,  cab- 
bages, carrots,  and  dandeloins  are  commonly  used  to  cure 
or  prevent  scurvy. 


302  THE    PREVENTION   OF   DISEASE 

Animals  fed  for  weeks  on  flours  of  various  grains  minus 
germs  and  hulls,  or  on  potatoes  which  have  been  dried 
and  then  boiled,  develop  scurvy.  It  has  long  been  taught 
that  only  milk  heated  to  high  temperatures  (108°  F.)  or 
boiled  caused  scurvy.  Hess  has  recently  shown  that 
heating  milk  to  145°  F.  (pasteurized  milk)  will  kill  vita- 
mins, and  produce  scurvy  in  infants  taking  it  exclusively 
without  orange  juice. 

Scurvy  in  infants  is  usually  caused  by  heated  condensed 
or  boiled  milk  or  infant  foods  of  all  kinds,  although  it  occa- 
sionally develops  when  the  baby  is  on  its  mother's  breast 
milk,  probably  depending  on  lack  of  vitamins  in  the 
mother's  food.  Cabbage  juice  loses  its  antiscorbutic 
(against  scurvy)  action  when  it  is  heated  to  145°  F.,  but 
lime  juice  boiled  one  hour  still  contains  its  vitamin  against 
scurvy.  For  the  reason  that  lime  juice  holds  its  antiscurvy 
property  so  tenaciously  it  is  the  great  preventive  of  scurvy 
in  English  ships,  called  popularly  "lime  juicers." 

Many  authorities  think  that  phosphorus  is  the  essential 
vitamin  in  food  which  prevents  scurvy  and  pellagra  as  well 
as  beriberi.  This  is  still  but  a  hypothesis. 

Scurvy  is  seen  in  infants  between  the  ages  of  six  and 
eighteen  months  usually,  and  in  those  who  have  lived  on 
boiled  or  condensed  or  proprietary  foods. 

The  first  symptom  is  shown  by  the  baby  crying  on  being 
moved  or  handled,  and  the  pain  is  chiefly  in  the  legs. 
The  baby  is  then  thought  to  have  rheumatism.  At  first 
the  baby  lies  with  the  legs  drawn  up,  but  after  a  while 
the  thighs  or  legs  swell  and  the  limbs  are  held  out  straight 
and  rigid,  with  the  toes  pointing  outward.  Neither  does 
the  baby  voluntarily  move  the  affected  leg  freely.  One 
limb  is  more  often  involved,  but  in  bad  cases  both  arms  and 
legs  are  attacked.  The  swelling  may  be  about  the  joints 
or  of  the  whole  limb.  When  there  are  teeth  the  gums  bleed 


RICKETS  303 

easily  and  there  may  be  purple  spots  on  the  skin,  blood  in 
the  urine,  and  rarely  in  the  bowel  discharges.  In  scurvy 
in  adults  and  infants  there  is  alteration  in  the  blood  and 
vessels,  and  a  tendency  to  hemorrhages.  In  scurvy  of 
infants  the  ends  of  the  bones  often  break  without  any 
apparent  cause. 

Prevention  of  scurvy  in  infants  may  be  absolutely  assured 
by  feeding  2  teaspoonfuls  of  orange  juice  or  juice  squeezed 
from  fresh  beef  three  times  daily.  Orange  juice  is  best  and 
should  always  be  given  when  pasteurized,  boiled  or  con- 
densed milk,  milk  powders  or  patent  foods  are  used. 
The  same  treatment  will  cure  babies  of  scurvy  within  a 
few  days  after  putting  the  patient  on  a  diet  of  unheated 
milk. 

Scurvy  in  adults  is  prevented  by  a  diet  containing  either 
fresh  meat,  milk,  vegetables,  or  fruit,  or  by  lime  juice  or 
other  antiscorbutic  articles  required  on  shipboard.  In 
adults  very  sick  with  scurvy  the  use  of  fresh  milk,  meat 
juice,  and  scraped  beef,  followed  by  potatoes,  lettuce,  and 
cabbage  when  the  digestion  is  stronger,  will  rapidly  cure 

the  disease. 

RICKETS 

Rickets  is  a  common  disease  of  infants  (occurring  in  50 
to  80  per  cent,  of  babies)  between  the  ages  of  three  months 
and  two  years  among  the  less  favored  classes  in  large  cities. 

It  is  essentially  a  disease  caused  by  improper  diet,  usu- 
ally occurring  in  infants  fed  on  condensed  milk,  pro- 
prietary foods,  or  on  cows'  milk  not  properly  diluted 
to  suit  the  digestion.  When  an  infant  nurses  the  breast 
more  than  nine  months  the  milk  will  usually  be  found 
deficient  in  quality.  Babies  who  are  fed  only  milk 
when  over  a  year  old  or  largely  starchy  proprietary  foods 
are  prone  to  rickets.  No  infant  who  receives  a  well- 
balanced  diet  and  assimilates  it  will  develop  rickets. 


304  THE   PREVENTION   OF   DISEASE 

Rickets,  like  pellagra,  is  apparently  due  to  a  diet  deficient 
in  proteins  and  perhaps  fats,  and  there  is  evidence  to  show 
that  sufficient  vitamin  is  also  lacking,  according  to  the 
theory  of  beriberi  and  other  of  these  nutritional  disorders. 
In  rickets  there  is  absorption  of  bone  already  formed  and 
impairment  in  the  bone-making  functions,  so  that  lime 
salts  are  not  readily  assimilated. 

Symptoms. — No  single  symptom  will  enable  us  to  diag- 
nose rickets,  but  only  the  general  picture  is  characteristic. 
The  infant  is  pale  and  puny,  with  soft,  flabby  flesh.  He 
seems  sore  on  being  handled  and  often  has  a  temperature 
of  100°  to  101°  F.  at  night.  The  head  is  large  for  the  body 
and  face,  teething  is  much  delayed,  and  the  soft  spot  in  the 
top  of  the  skull  may  not  close  until  the  third  or  fourth 
year.  The  normal  child's  head  increases  in  circumference 
about  4  inches  the  first  year  (3  inches  the  first  six  months) 
and  but  1  inch  the  second  year,  and  when  the  growth  is 
much  greater  the  case  is  apt  to  be  one  of  hydrocephalus 
rather  than  rickets.  Normally  the  first  teeth  (the  two 
lower  front  teeth)  appear  from  the  sixth  to  the  eighth 
month,  and  the  soft  area  in  the  top  of  the  head  is  closed 
with  bone  by  the  twentieth  month.  The  baby  is  fretful, 
subject  to  colds,  does  not  sleep  well,  and  sweats  about  the 
head  and  neck  at  night. 

The  chest  is  often  deformed,  so  that  the  breast  bone 
projects  (pigeon-breasted),  and  the  spine  may  be  bowed. 
There  is  often  a  vertical  row  of  little  lumps  on  the  ribs  on 
either  side  of  the  breast  bone.  The  child  is  pot-bellied  and 
bow-legged,  less  often  knock-kneed.  There  is  a  tendency 
to  attacks  in  which  the  child  loses  its  breath  and  gets  black 
in  the  face,  and  convulsions  are  not  infrequent. 

Prevention. — If  the  infant  is  on  cows'  milk  it  is  prob- 
ably too  rich  and  should  be  properly  diluted  (see  pages 
217-223),  or,  if  heated,  orange  juice  should  be  given. 


PELLAGRA  305 

Artificial  foods  and  condensed  milk  must  be  discontinued. 
After  the  first  year  meat  juice,  scraped  beef,  oatmeal, 
boiled  egg,  and  butter  should  be  added  to  the  milk  diet. 
Pure  god-liver  oil  (Peter  Moller's)  in  doses  of  10  to  30 
drops  at  six  months;  or,  from  six  to  twenty  months,  20  to 
60  drops  (or  a  teaspoonful),  given  three  times  daily  after 
meals,  is  most  beneficial.  The  baby  should  be  bathed  in  a 
brine  bath  at  night,  consisting  of  water  at  95°  F.,  to  which 
is  added  a  level  tablespoonful  of  salt  to  the  gallon.  Follow- 
ing this  2  teaspoonfuls  of  lard  or  cacao-butter  should  be 
thoroughly  rubbed  into  the  skin  for  ten  minutes. 

If  there  is  deformity  in  the  legs  or  back  the  child  should 
be  kept  on  his  back  most  of  the  time,  not  being  allowed  to 
stand  until  some  three  or  four  months  of  treatment  have 
elapsed.  There  should  be  plenty  of  fresh  air  in  the  room. 

PELLAGRA 

This  is  a  peculiar  disease,  beginning  in  Spain  (1762), 
spreading  to  Italy  and  France,  and  within  six  or  more 
years  becoming  quite  prevalent  in  the  southeastern  part  of 
the  United  States. 

The  digestion,  skin,  and  nervous  system  are  particularly 
affected.  The  disease  is  more  common  in  the  spring  and 
fall  and  return  of  the  disorder  is  also  frequent  at  these 
seasons.  It  occurs  in  persons  more  often  between  the  ages 
of  twenty  and  forty.  The  patient  feels  weak  and  de- 
pressed and  has  headache;  the  digestion  fails  and  there  is 
soreness  in  the  mouth,  nausea,  vomiting,  and  painful 
watery  or  bloody  diarrhea;  the  skin  on  the  backs  of  the 
hands,  face,  neck,  and  feet  becomes  red  and  puffy  and  looks 
as  if  it  were  badly  sunburned,  and  later  peels,  and  the  skin 
is  left  thickened  and  reddened.  In  the  more  severe  cases 
blisters  form.  The  nervous  symptoms  include  headache, 
dizziness,  mental  depression,  irritability,  change  in  disposi- 
20 


306  THE    PREVENTION   OF   DISEASE 

tion,  and  failure  in  mental  powers,  so  that  the  patient  hears 
imaginary  voices  or  sees  imaginary  objects.  Severe  cases 
occur  with  fever,  stupor,  delirium,  and  death  within  a  few 
weeks.  Chronic  cases  recur  in  spring  and  fall  from  year  to 
year,  with  failing  mentality  in  many  instances,  so  that 
patients  become  inmates  of  insane  asylums. 

Pellagra  is  not  contagious  nor  is  it  conveyed  by  flies  or 
other  means.  It  was  formerly  thought  to  be  due  to  eating 
Indian  corn,  especially  spoiled  corn.  Recently  the  United 
States  Public  Health  Service  has  declared  the  cause  of 
pellagra  to  be  the  eating  of  too  much  starch  or,  in  other 
words,  the  lack  of  vitamins  and  protein,  especially  during 
the  winter  months  in  the  South. 

It  is  affirmed  that  if  the  inhabitants  in  the  pellagra  sec- 
tion will  eat  sufficient  lean  meat,  eggs,  milk,  and  fresh  or 
dried  peas  and  beans  the  disease  will  be  prevented  and  in 
most  cases  patients  will  be  cured  by  such  a  regime.  A  daily 
winter  diet  for  patients  of  6  glasses  of  milk,  4  eggs,  and 
5  pound  of  lean  meat,  with  dried  peas  and  beans  or  pea 
or  bean  soup,  is  used  for  cure.  Patients  with  little  diges- 
tive difficulty  may  take,  in  addition  to  the  foregoing,  fruits, 
potatoes,  onions,  rice,  oatmeal,  and  wheat  and  rye  bread,  but 
no  corn  in  any  form.  Healthy  persons  living  in  the  pel- 
lagra section  should  see  that  their  diet  contains  a  liberal 
amount  of  lean  fresh  meat,  milk,  eggs,  and  in  winter  beans 
and  peas,  dried  but  not  canned.  By  such  means  the 
disease  may  be  prevented.  Corn  should  be  eaten  in  but 
small  amounts,  as  it  is  too  rich  in  starch.  The  Japanese 
beriberi  is  an  analogous  disease  apparently  caused  by  eat- 
ing polished  rice,  a  pure  starch  diet.  Pure  starch  and 
sugar  are  absolutely  wanting  in  vitamins  (see  page  297). 
Still  more  recently  (1915)  the  United  States  Public  Health 
Service  has  proved  their  contention  apparently  as  to  pel- 
lagra being  a  dietetic  disease.  Feeding  11  prisoners  at 


OBESITY  .       307 

Jackson,  Miss.,  on  cereals,  molasses,  potatoes,  sugar,  and 
syrup  for  six  months  6  contracted  pellagra.  Some  20  men 
living  under  precisely  the  same  conditions  in  the  same 
penitentiary,  except  for  the  special  diet,  failed  to  develop 
the  disease  in  a  single  instance.  -  It  is  only  proper  to  say 
that  many  students  of  the  cause  of  pellagra  differ  from 
the  government  authorities  as  to  its  origin,  believing  it  to 
be  due  to  some  specific  germ. 

OBESITY 

To  estimate  the  meaning  of  obesity  a  knowledge  of  the 
normal  weight  is  necessary.  In  the  table  on  page  308  is 
given  the  average  weight  of  healthy  men  for  different 
ages  and  heights. 

A  simple  rule  of  insurance  companies  is  that  a  weight  of 
over  3  pounds  to  the  inch  in  height  is  excessive,  while  a 
weight  under  2  pounds  to  the  inch  in  height  is  below  nor- 
mal. Weight  is  of  importance  in  respect  to  age.  Heavy 
weight  in  persons  over  forty  is  a  decided  disadvantage  from 
a  life  insurance  point  of  view,  their  death-rate  being  much 
above  the  average.  On  the  other  hand,  individuals  of 
light  weight  past  middle  age  have  as  good  an  expectancy 
of  life  as  those  of  normal  weight.  Young  persons  under 
weight,  especially  if  there  is  a  history  of  consumption  in 
the  family,  have  a  mortality  much  above  the  average.  In 
young  individuals,  otherwise  healthy  and  of  good  physique, 
overweight  is  not  unfavorable  from  the  insurance  view- 
point unless  the  abdominal  measure  exceeds  that  of  the 
chest,  which  is  undesirable  at  all  ages.  Insurance  statis- 
tics show  that  certain  diseases  occur  more  often  in  the 
stout  after  middle  age,  as  heart  disease,  bronchitis,  consti- 
pation, piles,  diabetes,  gout,  stone  in  the  kidney,  and 
Bright's  disease  of  the  kidney.  Hardening  of  the  arteries 
and  apoplexy  are  more  frequent  in  the  obese,  and  they  have 


308  THE   PREVENTION    OF   DISEASE 

TABLE  OF  HEIGHTS  AND  WEIGHTS 

Showing  the  Variations  from  Light  to  Heavy  Weight.      Within  these 
Limits  Build  is  Assumed  to  be  Normal.     (Fidelity  Mutual  Life 

Insurance  Co.) 

Ages 


Height 

15-29 

30-34 

35-39 

40-49 

50-60 

5ft  

f  117 
1  154 

114 

152 

110 
148 

106 
146 

103 
143 

1  118 

116 

111 

108 

104 

ft.  1  in  

t  156 

155 

151 

149 

145 

5ft.  2  in  

f  120 
1  159 

118 
157 

113 
153 

110 
151 

106 
147 

5ft.  3  in  

(123 
1  162 

121 
161 

116 
156 

112 
154 

108 
151 

5  ft.  4  in  

f  126 
\  166 

123 
164 

119 
161 

114 
157 

110 
154 

5ft.  5  in  

f  130 
1171 

127 
169 

122 
166 

118 
162 

113 
158 

f  133 

131 

126 

121 

116 

5  ft.  6  in  

\  176 

174 

170 

166 

162 

• 

j  137 

134 

129 

124 

120 

5  ft.  7  in  

1  181 

179 

175 

171 

167 

5ft.  Sin  

f  141 
1186 

139 
185 

133 
181 

128 
176 

124 
173 

5ft.  9  in  

/145 
\191 

142 
190 

138 
186 

132 

182 

128 
178 

5ft.  10  in  

f  149 
\  196 

147 
196 

142 
192 

136 

187 

131 
183 

5ft.  11  in  

f  153 

1  202 

151 
202 

146 
198 

141 
194 

135 
189 

6  ft  

/  159 
\210 

157 
209 

150 
205 

146 

200 

140 
195 

(165 

162 

156 

151 

145 

it.  1  in  

t  217 

216 

212 

208 

202 

6ft.  2  in  

f  170 
\  224 

167 
223 

162 
220 

157 
216 

150 
210 

(176 

173 

167 

162 

155 

ft.  o  in  

1  232 

230 

227 

223 

217 

less  resistance  to  surgical  operations  and  acute  diseases,  as 
pneumonia  and  typhoid  fever.  For  these  reasons  the 
insurance  companies  reject  or  handicap  overweight  indi- 
viduals at  or  after  middle  age  unless  there  is  a  family 
history  of  obesity  with  longevity.  As  to  the  cause  of 
obesity :  In  a  general  way  overeating  and  lack  of  exercise 


OBESITY  309 

are  responsible  for  much  fatness.  Heredity  is  important. 
The  secretions  of  certain  glands  in  the  body  are  absorbed 
into  the  blood  and  increase  or  diminish  the  tendency  to 
fat  formation.  Thus,  when  either  sex  is  castrated  (re- 
moval of  either  the  testicles  or  ovaries)  the  secretions  of 
these  glands  are  stopped  and  stoutness  is  apt  to  follow. 
The  same  result  occurs  at  the  change  of  life  in  women  when 
the  ovaries  cease  to  secrete.  Stoutness  is  seen  in  eunuchs 
and  in  women  whose  ovaries  are  removed  in  early  life  for 
disease.  With  partial  removal  (posterior  lobe)  or  disease 
of  the  pituitary  gland  at  the  base  of  the  brain  there  is  great 
increase  in  weight.  Giants  are  formed  through  disease  of 
this  gland.  Great  obesity  in  children  is  frequently  due  to 
disorder  of  the  pituitary  gland  and  is  often  associated  with 
poor  sexual  development. 

On  the  other  hand,  an  excess  of  secretion  of  the  thyroid 
gland  in  the  neck  produces  emaciation  in  some  forms  of 
goiter,  and  the  dried  sheep's  gland  is  sometimes  given  to 
reduce  obesity  in  man. 

Symptoms. — The  physical  inconvenience  caused  by  obes- 
ity and  the  injury  to  the  figure  in  women  are  the  com- 
mon complaints.  Walking  and  exertions  of  all  kinds  are 
difficult,  while  the  breathing  is  short  and  the  heart's  action 
is  embarrassed.  The  pulse  is  apt  to  be  more  rapid,  and 
the  urine  is  scanty  compared  to  the  amount  of  fluid  taken, 
because  of  easy  perspiration,  and,  for  the  same  reason, 
colds  are  more  frequent.  Indigestion  may  develop  and 
constipation  and  piles  are  common.  Impotence  some- 
times occurs  in  the  male.  Sleepiness  is  frequent  in  fat 
young  people,  as  made  famous  by  the  fat  boy  in  "Pickwick 
Papers."  Common  observation  shows  us,  however,  that 
obesity  is  compatible  with  not  only  long  life,  but  great  ac- 
tivity and  vigor,,-' 

Treatment. — All  reduction  cures  are  starvation  cures. 


310  THE   PREVENTION   OF  DISEASE 

None  supply  enough  food  for  the  permanent  needs  of  the 
body.  It  is  a  reduction  of  quantity  rather  than  quality 
of  food  which  counts.  Still,  the  kind  of  food  is  of  impor- 
tance. The  amount  of  food  given  in  reduction  cures  is 
equal  to  from  one-half  to  as  low  as  one-third  of  that  re- 
quired to  maintain  a  normal  individual.  The  fat  of  the 
body  is  thus  burned  up  to  supply  the  individual's  needs. 
The  danger  lies  in  the  fact  that  not  only  the  fat,  but  the 
substance  of  the  muscles  and  tissues  generally  may  also  be 
broken  up  if  the  starving  is  continued  too  long.  If  this 
happens,  the  subject  will  feel  weaker.  No  reduction  cure 
should  be  continued  unless  the  patient  feels  stronger  for  it. 
Frequent  meals  tend  to  prevent  a  feeling  of  weakness. 
As  a  general  rule  dieting  is  not  advisable  for  persons  over 
fifty  or  under  twenty.  Those  who  have  been  fat  for  a 
great  many  years  are  not  favorable  subjects  for  reduc- 
tion. Reduction  is  always  better  undertaken  under  a 
physician's  care,  and  it  should  never  be  carried  out  by 
the  patient  unless  otherwise  in  good  general  health.  The 
reduction  of  fat  in  certain  disorders,  as  in  tuberculosis, 
might  be  fatal. 

A  patient  should  not  lose  more  than  6  to  8  pounds  a 
month  for  two  or  three  months.  Then  the  diet  may  be 
increased  so  that  the  weight  is  maintained  at  a  level  for 
two  months  and  the  cure  instituted  again.  None  but 
robust  individuals  should  lose  as  much  as  40  or  50  pounds 
in  a  year,  and  they  should  feel  the  stronger  for  it.  Fatness 
in  children  should  be  discouraged  by  the  avoidance  of 
sweets,  starches,  as  cereals  and  fats,  and  by  the  use  of 
outdoor  exercises,  but  not  by  a  strict  diet. 

Food  is  generally  divided  into  fats,  starches  and  sugar, 
and  proteins.  The  latter  include  pure  meat  and  fish  free 
from  fat,  skimmed  milk,  white  of  egg,  and  a  portion  of 
vegetables,  as  gluten  in  flour.  Proteins  build  tissue  in  the 


OBESITY  311 

growing,  and  repair  it  in  adults,  but  do  not  make  fat. 
Sugar,  starches,  and  fat  make  fat  and  must  be  chiefly 
cut  out  in  the  reduction  diets.  In  the  following  diet  list 
the  fat  is  but  one-third  to  one-half  and  the  starches  and 
sugars  but  one-fifth  to  one-half  of  what  are  required  in  a 
normal  diet,  while  the  amount  of  proteins  is  about  the 
standard  for  normal  adults.  The  special  diets  given  in 
most  medical  text-books  are  of  German  origin,  as  Oertel's, 
von  Noorden's,  Epstein's,  etc.,  and  include  articles  often 
not  palatable  to  us,  as  cold  meat  for  breakfast,  Rhine  wines 
in  considerable  amount,  etc. 

The  following  diets  are  those  particularly  in  vogue. 

The  Oertel  cure  requires  that  the  liquid  be  reduced  to 
2|  pints,  including  water  and  all  other  fluids  taken  in  the 
twenty-four  hours,  thus: 
Breakfast:  6  ounces  of  tea  or  coffee  with  milk  and  3 

ounces  of  bread. 
Lunch:  3  to  4  ounces  of  soup,  7  to  8  ounces  of  meat,  a 

little  fish,   1  ounce  of  bread  or  sago,  rice,  tapioca 

pudding,  3  to  6  ounces  of  fruit  for  dessert,  1  glass  of 

water. 
Afternoon  Tea:  6  ounces  of  tea  and  a  glass  of  water,  1 

ounce  of  bread. 
Supper:  1  or  2  soft-boiled  eggs,  1  ounce  of  bread,  small 

slice  of  cheese,  salad  and  fruit,  1  to  2  glasses  of  liquid. 

von  Noorden's  diet  follows: 

Breakfast  (8  A.  M.):  Lean  meat  2f  ounces,  1  cup  of  tea 
with  spoonful  of  milk,  no  sugar,  bread  £  ounce. 

10  A.  M.:  One  egg. 

12  M.:  A  cup  of  strong  meat  broth. 

1  A.  M.:  A  small  plate  of  vegetable  and  meat  soup,  5 
ounces  of  meat  and  fish,  3  ounces  of  potatoes  with 
salad,  3|  ounces  of  fresh  fruit  without  sugar. 


312  THE   PREVENTION   OF   DISEASE 

4  P-  M.:  6|  ounces  of  fresh  fruit. 

6  P.  M.:  \  pint  of  milk  with  tea. 

8  P.  M.:  4  ounces  of  cold  meat  or  6  ounces  of  raw  meat 
cooked  and  eaten  with  salad,  1  ounce  of  Graham 
bread  and  2  or  3  spoonfuls  of  cooked  fruit  without 
sugar. 

The  amount  of  liquids,  as  water,  weak  tea  or  lemonade, 
at  or  between  meals  is  not  limited,  von  Noorden  believes 
the  numerous  small  meals  prevent  weakness. 

Bouchard's  diet  consists  wholly  of  1\  pints  of  milk  and 

5  eggs  per  day;  in  other  words,  a  glass  of  milk  and  1  egg  at 

7  and  11  A.  M.  and  3,  7,  and  11  p.  M.  for  twenty  days. 

Most  of  the  diets  cut  down  on  starches,  fat,  and  sugar 
required  in  a  normal  diet,  while  increasing  from  one-third 
to  one-half  the  amount  of  proteins  as  represented  by  meat, 
fish,  milk,  and  egg.  They  represent  about  one-half  the 
food  value  required  by  the  normal  person. 

The  so-called  milk-cure  is  one  of  the  simplest  and  may 
be  used  even  in  disease  of  the  heart 'or  kidneys  (with  a 
doctor's  permission),  as  it  increases  the  action  of  the  kid- 
neys and  is  particularly  applicable  in  the  case  of  persons 
with  abdominal  fat. 
Breakfast:  1  pint  of  milk. 

Lunch:  6  ounces  of  lean  meat  with  green  vegetables,  as 
spinach,  green  peas,  string  beans,  lettuce.  (No 
bread  or  potatoes,  but  beets,  turnips,  parsnips,  cab- 
bage, Brussels  sprouts,  carrots  may  be  used  in  place  of 
green  vegetables.)  One-half  pint  of  milk,  2  glasses 
of  water  or  cups  of  tea  with  a  little  sugar. 
Tea  (5  P.  M.}:  \  pint  of  milk  or  junket,  2  cups  of  tea  with 
a  little  sugar. 


OBESITY  313 

Supper  (7  P.  Af.)-'  1  pint  of  milk  and  2  apples  (they  may 

be  cooked). 

In  place  of  the  midday  meal  only  1  pint  of  milk  may 
be  taken  in  the  case  of  robust  persons.  If  the  subject 
remains  at  home  he  may  take  the  milk  more  frequently, 
8  to  9  glasses  daily,  with  only  the  apples,  tea,  and  water,  if 
the  noon  meal  is  abstained  from. 

Ebstein's  diet  contains  3  pints  of  liquid,  including  2  cups 

of  tea,  as  follows: 

Breakfast:  Bread,  2  ounces,  with  plenty  of  butter  (bread 
may  be  toasted) ;  large  cup  of  tea  at  end  of  meal,  with- 
out sugar. 

Lun^h:  Fat  meat,  ham,  or  fish,  4  ounces,  or  1  egg,  bread 
and  butter,  1  ounce;  green  vegetables  or  salad  and 
fruit. 

Tea:  Cup  of  tea,  one  slice  of  bread  and  butter,  or  biscuit. 

Dinner:  Cleat  soup,  meat  5  or  6  ounces,  cabbage,  peas, 
string  beans  or  spinach,  as  much  as  wanted,  raw  fruit 
or  salad,  small  piece  of  cheese  and  a  cup  of  tea  at  end 
of  meal,  5  glasses  of  water  should  be  taken  between 
meals.  This  diet  allows  fats,  but  excludes  starches 
and  sugar,  and  contains  half  the  normal  food  require- 
ments. 

Dr.  E.  A.  Locke's  diet  has  been  found  by  the  writer  the 

most  sensible  and  is  in  accord  with  our  customs.     It 

follows : 

Breakfast:  1  cup  of  black  coffee  (no  cream  or  sugar), 
1  or  2  boiled  or  poached  eggs,  1  or  2  small  slices  of 
toast  without  butter,  an  orange,  apple,  pear,  or  one- 
half  a  grapefruit. 

11.30  A.  M.:  A  glass  of  milk,  buttermilk,  or  some 
fruit. 


314  THE    PREVENTION    OF   DISEASE 

Luncheon:  One  cup  of  clear  soup,  3  ounces  of  meat,  eggs, 
or  fish,  two  varieties  of  green  vegetables,  2  to  4  ounces 
each,  raw  fruit. 

5  P.  M.:  Tea  without  cream  or  sugar,  one  small  slice  of 
toast. 

Dinner:  Raw  oysters,  lean  met  or  fish,  4  to  5  ounces,  two 
green  vegetables,  2  to  4  ounces  each,  salad  of  fruit  or 
vegetables  with  a  small  amount  of  French  dressing, 
raw  or  unsweetened  cooked  fruit,  demi-tasse  of  black 
coffee. 

The  following  articles  are  to  be  avoided: 

Starches.— White  potatoes,  except  in  small  amount, 
bread,  crackers,  cereals,  macaroni,  vermicelli,  spaghetti, 
sago,  tapioca,  cornstarch,  sweet  potatoes,  shell  beans, 
dried  peas  or  beans,  corn,  and  nuts. 

Sweets. — Sugar,  candy,  dried  fruits,  syrups,  fruit  pre- 
serves, honey,  marmalade,  and  sweet  sauces. 

Meat. — Pork,  bacon,  goose,  sausage,  croquettes. 

Fish. — Shad,  fresh  salmon,  eels,  sardines,  mackerel, 
bluefish,  and  fried  fish. 

Fats, — Butter,  cream,  olive  oil,  bacon,  lard,  fat  meat,  and 
fish. 

Dessert. — Ices,  rich  puddings,  cake. 

Miscellaneous. — Chocolate,  alcoholic  drinks,  except 
claret  and  Rhine  wines,  thick  soups,  milk,  cheese,  pickles, 
condiments. 

This  diet  contains  a  third  to  a  little  over  one-half  the 
food  value  required  by  a  normal  person  weighing  150 
pounds.  For  a  heavy  person  the  food  is  correspondingly 
deficient,  so  that  he  will  live  on  his  fat  while  on  the  diet. 

Water  is  not  curtailed  in  Locke's  diet,  as  in  many  diets 
for  reducing  fat,  but  water  should  only  be  taken  after 
rising  and  between  meals  and  at  bedtime. 


OBESITY  315 

Water  taken  at  meals  increases  the  appetite,  and  some 
authorities  believe  the  absorption  of  food  as  well. 

It  is  advisable  that  the  patient  should  actually  weigh 
his  food  at  first  and  then  he  can  judge  later  of  the  amount 
he  should  take  by  bulk.  The  patient  should  weigh  himself 
daily  and  keep  a  weekly  chart  of  his  weight.  The  appe- 
tite will  be  hard  to  curb  at  first,  but  after  a  few  weeks  there 
should  be  no  trouble  on  this  score  and  the  strength  and 
appearance  should  improve.  Prolonged  chewing  lessens 
the  appetite. 

The  diet  may  be  followed  until  the  weight  becomes 
normal  for  the  height  of  the  subject.  Then  the  diet  may 
be  somewhat  increased,  being  careful  not  to  take  too 
much  sugar,  fat,  and  starches,  as  potatoes  and  bread. 
Exercise  is  most  important  during  the  cure,  and  swimming, 
riding,  golf,  and  walking,  as  three-quarters  of  an  hour  in 
the  morning  and  one-half  hour  in  the  afternoon,  are  to  be 
recommended.  Exercise  with  a  heavy  sweater  on  will 
greatly  reduce  weight  through  perspiration,  providing 
water  is  taken  but  moderately.  Massage  will  to  some 
extent  reduce  local  accumulations  of  fat,  as  on  the  abdo- 
men, but  it  must  be  given  daily  and  very  vigorously  for 
this  purpose.  Special  exercises  are  more  efficient,  as 
exercises  in  bending  over  for  removal  of  fat  on  the  abdo- 
men. Sometimes  cathartics  are  necessary,  especially  on 
cutting  down  the  bulk  of  food.  Some  saline,  as  Carlsbad 
salts  in  ^-teaspoonful  doses  (more  or  less)  in  a  glass 
of  cold  water  on  rising,  is  suitable. 

The  whole  success  of  the  treatment  depends  upon  the 
faithfulness  with  which  it  is  carried  out.  If  thoroughly 
done  the  habits  will  become  so  changed  that  it  will  not  be 
difficult  to  adhere  to  a  proper  diet  thereafter. 


316  THE    PREVENTION    OF   DISEASE 

PREVENTION  OF  DIABETES 

Prevention  -applies  especially  to  the  children  of  diabetic 
parents.  These  should  be  brought  up  on  a  diet  from  which 
candy,  cake,  and  sweets  generally  are  largely  excluded. 
Testing  the  urine  at  least  four  times  a  year  in  the  children 
of  diabetics,  in  fat  adults  and  in  their  children,  and  in  those 
who  have  previously  had  sugar  in  their  urine,  is  of  the  ut- 
most importance.  Since  there  is  an  association  of  dia- 
betes with  obesity  the  stout  and  their  children  should 
reduce  their  weight  by  appropriate  diet  and  exercise  (see 
page  310). 


CHAPTER  XVII 
THE  PREVENTION   OF  SOME  DEFORMITIES 

INTRODUCTORY    NOTE 

THE  way  the  human  body  is  used  is  of  the  utmost  importance  if 
proper  health  and  efficiency  of  the  individual  are  to  exist,  and  to 
prevent  the  common  deformities  seen  in  human  beings  the  appre- 
ciation of  this  fact  is  of  the  greatest  consequence. 

If  the  body  is  used  fully  erect  the  muscles  as  a  whole  are  in  their 
best  position  for  development.  The  ligaments  naturally  strengthen, 
the  bones  develop  without  deformity,  and  the  greatest  amount  of 
physical  energy  is  available  for  work.  In  this  position  also  the 
chest  is  so  held  that  the  lungs  develop  properly,  the  heart  is  free  to 
perform  its  work,  and  the  abdomen  is  so  shaped  that  none  of  its 
organs  is  harmfully  interfered  with. 

If  the  body  is  drooped,  however,  not  only  are  the  shoulders 
thrown  forward,  but  the  spine  is  curved,  the  knees  and  ankles  are 
sprung,  and  the  chest  is  flattened — embarrassing  the  action  of  the 
lungs — so  that  in  consequence  the  diaphragm  is  forced  downward 
and  the  abdominal  wall  is  relaxed,  with  the  natural  effect  that  the 
abdominal  organs  are  not  properly  supported  and  are  crowded  out 
of  then-  normal  position,  frequently  resulting  in  disaster. 

The  chapter  which  follows  admirably  suggests  the  different 
features  which  are  of  importance  in  this  matter  of  the  prevention 
of  deformities.  These  if  recognized  in  childhood  and  properly 
treated  will  result  in  our  seeing  develop  about  us  strong  and  healthy 
boys  and  girls. 

JOEL  E.  GOLDTETWAIT. 

Round    Shoulders,  Lateral   Curvature  of  the   Spine,   Humpback, 
Knock-knees,  Bow-legs,  Weak  Ankles,  Weak  Feet  and  Flat-feet 

Deformities  depend  upon  weakness  of  the  muscles 
and  ligaments  and  upon  disease  of  the  bones.  Bad  hygiene 

317 


318  THE    PREVENTION    OF   DISEASE 

in  the  child  favors  general  weakness  and  thus  deformities. 
That  is,  lack  of  proper  food,  exercise  outdoors,  fresh  air, 
etc.  The  special  diseases  of  infancy  predisposing  to  defor- 
mities are  rickets  and  scurvy,  which  are  considered  in 
another  place.  In  rickets,  where  the  bones  are  soft,  the 
child  should  be  encouraged  to  creep  and  discouraged  to 
stand.  Rest  in  bed  until  a  cure  is  obtained  is  often  ad- 
visable. The  diseases  which  directly  cause  deformities 
are  infantile  paralysis  from  weakness  and  paralysis  of 
the  muscles,  and  tuberculosis,  syphilis,  and  gonorrhea, 
which  primarily  produce  disease  of  the  bones. 

But  the  more  common  deformities  which  we  will  con- 
sider are  those  caused  by  general  weakness  or  faulty  pos- 
tures assumed  during  standing,  sitting,  walking,  sleeping, 
playing,  or  working.  These  include  round  shoulders,  cur- 
vature of  the  spine,  bow-legs,  knock-knees,  weak  ankles, 
and  flat-feet. 

Round  Shoulders  and  Spinal  Curvature. — Round  shoul- 
ders and  lateral  curvature  of  the  spine  are  exceedingly  com- 
mon. Many  of  the  same  causes  act  to  produce  one  or 
both  of  these  deformities.  In  round  back  or  round  shoul- 
ders the  subject  assumes  a  position  shown  in  Figs.  8  and 
9,  with  back  arched,  chin  thrust  forward,  chest  flat,  and 
lower  belly  prominent.  It  follows  that  if  the  back  is 
bowed  backward  the  lower  part  of  the  abdomen  must  be 
carried  forward  to  preserve  the  proper  balance.  This 
position,  besides  being  a  great  deformity,  interferes  with 
the  free  action  of  the  lungs  and  heart  and  causes  the 
abdominal  organs  to  be  pushed  downward,  leading  to  one 
of  the  most  common  forms  of  indigestion  and  having  far- 
reaching  consequences  (see  page  276).  In  lateral  curva- 
ture the  spinal  column,  instead  of  occupying  a  vertical 
position,  becomes  deviated  from  side  to  side  so  that  it  has 
a  more  or  less  S-shape  when  viewed  from  behind.  This 


ROUND    SHOULDERS    AND    SPINAL   CURVATURE         319 

deformity  is  more  frequent  in  young  girls  (from  ten  to 
fifteen  years)  and  is  often  first  noticed  by  the  dressmaker, 
because  one  breast  is  more  prominent  than  the  other  or 
because  one  hip  or  shoulder  is  higher  than  its  mate.  In 
Fig.  11  is  shown  an  outline  of  the  back  in  a  case  of  lateral 
curvature.  In  the  upper  part  of  the  back  the  deviation  is 
toward  the  right  and  in  the  lower  part  toward  the  left. 


Fig.  9. 


Fi?.  10. 


The  right  shoulder  and  left  hip  are  higher  than  their  mates 
and  the  left  breast  (not  shown  in  the  diagram)  is  also  more 
prominent.  When  this  patient  stoops,  holding  the  heels 
together  without  bending  the  knees  and  .inclines  the  body 
forward  from  the  hips  with  the  head  and  arms  hanging 
down,  we  will  observe  the  deformity  of  the  back  as  in  Fig. 
12.  This  outline  shows  the  ribs  bulging  outward  to  the 


320 


THE    PREVENTION    OF   DISEASE 


right  of  the  spinal  column  owing  to  the  fact  that  some  of 
the  vertebrae  are  twisted  to  the  right  side  in  addition  to 
the  deviation  of  the  whole  spinal  column.  By  marking 


Fig.  11. 


Fig.  12. 


with  ink  the  bony  prominences  along  the  spine  from  the 
neck  downward  one  can  readily  see  whether  the  spine  is 
straight  or  not,  as  in  Fig.  11. 


Fig.  13. — Humpback   in  early  stage,  showing  sharp  projection  in 
back  bone.  • 

Lateral  curvature  of  the  spine  is  capable  of  causing 
the  most  frightful  deformity  if  it  becomes  marked,  al- 
though, considering  its  frequency,  this  does  not  often 


ROUND    SHOULDERS   AND    SPINAL    CURVATURE 


321 


occur.     It  also  gives  rise  to  pain  in  the  back  as  a  common 
symptom. 

The  ordinary  humpback  (Figs.  13,  14)  is,  of  course,  not 
due  to  the  subject's  weakness  and  slovenliness,  and  is  gen- 
erally much  more  marked  than  in  round  shoulders  or  stoop- 
back.  The  distinction  between 
the  two  is  that  in  humpback 
the  projection  in  the  back  is 
sharp  in  the  beginning,  owing  to 
tuberculosis  of  one  or  more  ver- 
tebrae, and  the  back  is  painful 
and  stiff  on  movement,  and  pains 
are  felt  in  the  abdomen.  In  the 
course  of  time  the  deformity 
becomes  much  greater  than  in 
round  shoulders,  although  there 
are  some  cases  which  at  first 
sight  look  like  humpback,  but 
the  history  of  the  case  and  lack 
of  pain  and  stiffness  in  round- 
back  will  serve  to  distinguish  it 
from  humpback. 

Prevention  of  back  deformities 
must  begin  in  infancy  by  the  use 
of  proper  diet,  and  by  giving  the 
child  proper  care  generally,  to 
avoid  such  conditions  as  malnutrition,  anemia,  rickets, 
and  scurvy,  in  which  the  soft  tissues  become  weakened 
(muscles  and  ligaments)  and  the  bones  soft. 

Mothers  will  find  such  a  book  as  "Holt's  Care  of  the 
Baby"  invaluable  in  this  connection.  Tuberculosis  in 
children  is  the  commonest  cause  of  bone  diseases  and  may 
be  avoided  by  the  exclusive  use  of  properly  pasteurized 
milk  (see  page  287)  in  many  cases.  It  is  still  more  im- 
21 


Fig.  14. — Humpback, 
showing  distinct  bony 
projection  from  the  spine. 


322  THE   PREVENTION    OF   DISEASE 

portant  to  prevent  exposure  of  a  child  to  a  tuberculous 
patient  in  the  home.  This  matter  has  been  discussed 
under  Tuberculosis.  Other  common  causes  of  joint 
and  bone  diseases  are  syphilis  and  gonorrhea,  described 
elsewhere.  Infantile  paralysis  is  usually  followed  by 
deformities  and  must  be  avoided  if  possible  (see  page 
141).  As  round-back  and  lateral  curvature  of  the  spine 
are  due  in  large  part  to  general  weakness,  the  encourage- 
ment of  the  general  development  and  vigor  are  of  prime 
importance  by  means  of  proper  physical  training,  games, 
and  sports.  In  school  the  child  should  sit  in  proper  posi- 
tion at  an  appropriate  desk.  The  narrow  chair  with 
straight  back  at  right  angles  with  its  seat,  having  an  ad- 
justable cross-piece  to  support  the  small  of  the  back  of  the 
pupil,  has  been  found  most  suitable.  The  pupil  should 
not  carry  heavy  books  to  and  from  school,  as  one-sided 
postures  in  standing,  sitting,  working,  and  playing  all  tend 
to  produce  lateral  curvature  of  the  spine.  Nurse  girls 
who  carry  a  baby  under  one  arm,  or  grocers'  boys  laden 
down  with  provisions,  often  show  marked  deformity  of  the 
spine  in  consequence. 

The  same  remark  applies  to  young  persons  in  factories. 
At  school  frequent  recesses  give  the  pupils  fresh  air  and 
change  of  position.  Children  should  be  made  to  stand 
with  the  head  up,  as  if  they  were  being  measured  and 
were  trying  to  make  themselves  as  tall  as  possible 
without  actually  standing  on  tiptoes  (Goldthwait).  This 
position  throws  the  chest  up  and  out  and  draws  the 
shoulders  back  and  the  lower  part  of  the  belly  in. 
The  feet  should  be  held  straight,  and  toeing  out  must 
not  be  allowed.  Weak  feet,  ankles,  and  legs  will  often 
cause  a  one-sided  posture,  as  in  this  case  one  leg  may 
be  a  little  shorter  than  its  fellow  and  lateral  curvature 
of  the  spine  will  result.  Astigmatism  and  deafness  may 


ROUND    SHOULDERS    AND    SPINAL    CURVATURE        323 

cause  the  pupil  to  hold  his  head  on  one  side  (thus  fa- 
voring lateral  curvature)  in  trying  to  see  and  hear,  and 
these  must  be  corrected — astigmatism  by  glasses,  and  deaf- 
ness often  by  removal  of  enlarged  tonsils  and  adenoid 
growths.  These  diseases  also  greatly  reduce  the  vitality 
and  general  health.  Their  surgical  cure  is,  therefore,  im- 
perative. Certain  sports  are  particularly  good  in  the  pre- 
vention of  deformities  caused  by  round-back  or  lateral  curv- 
ature. Thus,  swimming  with  the  breast-stroke  (not  side- 
stroke),  riding  astride,  running  and  climbing,  baseball, 
cricket,  and  football  are  desirable.  Where  there  is  a  tend- 
ency to  lateral  curvature,  side  saddle  riding,  tennis,  and 
golf  may  be  inadvisable,  although  I  have  known  golf  to 
cure  lateral  curvature  by  its  general  effect  in  toning  up 
the  body  through  the  invigorating  outdoor  exercise. 

The  patient  in  this  instance  was  a  delicate,  nervous  girl, 
the  more  common  type  of  patient  with  this  deformity. 
Dress  is  most  important  in  young  children.  Straps  hold- 
ing up  the  clothing  should  always  be  made  to  bear  on  the 
shoulders  next  the  neck,  as  do  men's  suspenders,  and  not 
be  placed  so  that  they  pass  over  the  outer  part  of  the 
shoulders.  This  position  of  the  straps  tends  to  cause  the 
shoulders  to  droop  and  induces  round  shoulders  (Goldth- 
wait). 

Instruction  in  singing  is  much  to  be  preferred  to  lessons 
in  instrumental  mucic  where  the  positions  are  bad  (as  in 
playing  the  violin  or  piano).  In  singing  the  subject  must 
stand  erect  and  learn  how  to  breathe  properly  and  lift  and 
fill  the  chest  with  air. 

Round-back  is  part  and  parcel  of  general  weakness,  as 
shown  by  weak  ankles  and  turned  out  feet  (see  Figs.  17, 18), 
and  increasing  the  vigor  of  the  body  by  exercises,  alter- 
nated with  proper  rest  (the  use  of  a  low  pillow  at  night  or 
none),  is  more  important  than  braces  or  back  supports, 


324 


THE    PREVENTION    OF   DISEASE 


although  these  have  occasionally  to  be  used.  Considera- 
tion of  the  actual  treatment  of  the  deformities  resulting 
from  round-back  or  lateral  curvature  of  the  spine  is  out 
of  our  province,  but  it  consists  chiefly  in  well-directed  exer- 
cises and  occasionally  (in  lateral  curvature)  in  the  use  of 
special  apparatus  and  even  plaster  casts.  This  treatment 
may  best  be  undertaken  by  the  orthopedic  surgeon. 


KNOCK-KNEES  AND  BOW-LEGS 

Both  these  conditions  (Figs.  15,  16)  are  due  to  general 
weakness  or  disease  of  the  bones,  particularly  rickets. 


Fig.  15. — Bow-legs  (after  Taylor). 


Fig.    16. — Knock-knees   (after 
Taylor). 


They  are  common  deformities  of  young  children.  In 
knock-knees  there  is  weakness  of  the  knees  owing  to  the 
stretching  of  the  ligaments  on  the  inside  of  the  knees. 
Carrying  heavy  weights  and  standing  too  much  may  bring 
on  knock-knee  in  older  children.  The  feet  are  naturally 


WEAK    FOOT    AND   FLAT-FOOT  325 

weak  and  turned  out  (see  page  326)  unless  they  are  pur- 
posely carried  straight  or  turned  in  to  counteract  the 
weakness  in  the  knees.  The  gait  is  awkward  and  the  knees 
may  knock  together  in  walking.  The  deformity  is  due 
either  to  a  bending  of  the  lower  part  of  the  thigh  bone  or  the 
upper  end  of  the  chief  bone  of  the  leg,  or  both.  Only  one 
leg  may  be  involved,  but  more  often  both  legs.  Occasion- 
ally one  limb  may  have  the  bow-leg  and  the  other  the 
knock-knee  deformity.  In  bow-legs  the  deformity  com- 
monly occurs  below  the  knees  in  the  chief  leg  bone  (tibia), 
although  the  thigh  bones  may  also  be  bent  out  of  line. 

Prevention  and  Treatment. — Children  with  rickets  should 
be  under  treatment  for  some  months  before  they  are  per- 
mitted to  stand.  When  the  condition  of  knock-knees  is 
not  pronounced,  so  that  the  distance  between  the  ankles 
in  standing  is  not  greater  than  2  inches,  the  deformity 
may  be  corrected  by  making  the  inside  of  the  sole  of  the 
shoe  \  inch  thicker,  so  as  to  throw  the  weight  on  the  outer 
side  of  the  foot  and  take  the  strain  off  the  inner  border  of 
the  foot  and  the  weak,  inner  side  of  the  knees.  In  con- 
spicuous cases  of  knock-knees  or  bow-legs  braces  should  be 
applied  by  an  orthopedic  surgeon  in  the  case  of  children 
under  four  who  are  walking.  In  severe  cases  operation 
is  necessary  in  either  knock-knees  or  bow-legs  affecting 
children  over  four  years  of  age.  This  consists  in  surgically 
breaking  the  deformed  bones  under  an  anesthetic  and  then 
setting  the  bones  in  proper  position  in  a  plaster-of-Paris 
cast.  The  operation  is  practically  without  danger.  If 
the  operation  is  done  too  early,  as  under  four  years,  the 
deformity  may  recur. 

WEAK  FOOT  AND  FLAT-FOOT 

These  conditions  are  often  seen  in  young  children,  as 
well  as  in  adults  who  stand  at  their  work,  and  should  be 


326 


THE    PREVENTION    OF   DISEASE 


corrected  in  their  earlier  stages  before  actual  deformity 
occurs. 

In  weak  ankles  there  is  usually  a  tendency  to  flat-feet. 
In  standing,  the  characteristics  of  weak  ankles  are  most 
apparent.  These  consist  in  prominence  of  the  bones  on  the 
inside  of  the  ankles,  as  seen  in  Fig.  17.  Moreover,  the  sul> 
ject  stands  with  the  feet  hold  apart  and  the  toes  well  turned 
out,  as  in  Fig.  18.  It  was  not  so  long  ago  that  children 


Fig.  17. 


Fig.  18. 


were  taught  to  turn  their  toes  out  in  walking,  and  they 
were  being  continually  corrected  for  failure  to  assume  this 
position. 

The  feet  should  be  held  in  a  straight  line,  neither 
toeing  out  or  in  while  walking,  although  the  slightly  toeing 
in  position  is  better  than  toeing  out. 

Both  weak  ankles  and  flat-foot  are  caused  by  weakness 
of  the  ligaments  and  muscles  of  the  foot.  In  weak  ankles 


WEAK    FOOT    AND    FLAT-FOOT 


327 


the  weight  tends  to  fall  on  the  inside  of  the  foot,  as  in  Fig. 
19,  so  that  the  arch  of  the  foot  gives  way  on  the  inner  side 
and  the  entire  sole  of  the  foot  rests  on  the  floor.  This  is 
called  flat-foot.  Ordinarily  only  the  outer  half  of  the  foot 
touches  the  floor  in  walking  (Fig.  20) .  To  determine  the 
presence  of  flat-foot  the  soles  of  the  feet  may  be  smeared 
with  vaselin,  and  then  the  patient  may  stand  upon  blotting 
paper  to  leave  the  impression  of  the  feet;  or,  the  soles  of 


Fig.  19. — Foot  seen 
from  behind. 


Fig.  20. 


Fig.  21. 


the  feet  may  be  brushed  over  with  charcoal  and  the  sub- 
ject may  stand  upon  white  paper.  In  Fig.  20  is  seen  the 
impression  of  a  normal  foot,  while  in  Fig.  21  is  shown  an 
impression  of  a  very  marked  case  of  flat-foot.  In  adults 
who  develop  flat-feet  because  their  occupation  requires 
them  to  be  on  their  feet  continually,  as  in  the  case  of  nurses, 
policemen,  etc.,  there  is  often  great  discomfort  or  pain. 
This  condition  is  commonly  thought  to  be  rheumatism. 


328 


THE    PREVENTION    OF   DISEASE 


There  may  be  pain  and  tenderness  under  the  sole  of  the 
feet,  about  the  ankles,  under  the  heel,  or  under  the  outer 
ankle  bone,  and  even  in  the  calves  of  the  legs,  knees, 
thighs,  hips,  or  back.  Persons  who  stand  much  and  have 
flat-feet  and  pain  in  the  knees,  hips,  or  back  are  often 
treated  for  rheumatism,  or,  if  women,  for  womb  trouble. 
On  looking  at  the  shoes  of  persons 
with  weak  ankles  and  flat-feet  it  will 
be  seen  that  there  is  unusual  wear  on 
the  inner  edge  of  the  soles,  owing  to  the 
weight  bearing  chiefly  on  the  inside  of 
the  feet  (see  Fig.  19).  As  we  are  dealing 
in  prevention,  it  is  not  within  our  pro- 
vince to  consider  treatment  of  chronic 
and  bad  cases  of  flat-feet  which  often 
need  forcible  correction  of  the  deformity 
by  a  surgeon  and  rest  in  bed  with  the 
feet  in  a  plaster  cast.  Even  marked 
cases  of  flat-feet,  which  require  plates  to 
hold  up  the  inner  side  of  the  soles  of  the 
feet,  should  go  to  the  orthopedic  surgeon 
for  the  fitting  of  plates  rather  than  con- 
sult the  shoe  man,  who  will  supply  the 
ready-made  articles  so  commonly  worn. 
To  prevent  flat-foot  in  the  case  of  weak  ankles  and  feet  in 
children  and  adults  who  stand  at  their  work  the  following 
advice  may  be  given: 

In  the  first  place  the  proper  shoe  should  be  worn. 
Such  a  shoe  as  is  shown  in  Fig.  22  is  of  service  and  is  often 
sold  under  the  name  of  anatomic  or  orthopedic  shoe.  The 
sole  forms  a  straight  line  on  the  inside  of  the  shoe,  so  that 
the  patient  may  have  more  bearing  on  the  part  where  the 
greater  weight  comes,  and  the  heel  of  the  shoe  is  extended 
forward  and  inward  for  the  same  reason.  This  feature  in 


Fig.  22. 


WEAK    FOOT   AND    FLAT-FOOT  329 

the  heel  is  a  counterpart  of  the  great  toe  in  the  barefoot 
savage  which  spreads  out,  or  really  in — that  is,  away  from 
the  outside  of  the  foot — and  prevents  the  foot  and  ankle 
from  giving  away  as  in  weak  ankle.  Straight-foot  walk- 
ing and  standing  should  then  be  practised.  The  raising 
of  the  inner  side  of  the  sole  of  the  shoe  throws  the  weight 
of  the  body  more  on  the  outer  side  of  the  foot,  and  this  is 
sometimes  accomplished  by  an  added  sole  piece  about  YS 
inch  thick  (see  Fig.  22),  or  by  making  the  whole  sole 
this  much  thicker  along  its  inner  border. 

Exercises  in  bare  or  stockinged  feet  are  also  essential. 
The  following  are  recommended: 

(1)  Walk  about  the  room  three  to  five  minutes  with  the 
toes  pointing  inward  and  the  heels  slightly  raised  from  the 
ground  (on  tiptoes). 

(2)  With  the  toes  turned  in  walk  on  the  outer  border  of 
the  feet  three  to  five  minutes. 

(3)  Stand  with  the  toes  turned  in,  quickly  raise  the  heels, 
and  slowly  come  down  on  the  outer  borders  of  the  feet 
(three  to  five  minutes). 

(4)  While  standing,  rise  on  the  toes,  turn  the  heels  out- 
ward; lower  the  heels  slowly  to  the  floor. 

The  trained  masseuse  will  also  be  of  much  service  to 
children  in  manipulating  the  feet.  Children  should  have 
times  for  rest  and  should  practice  walking  straight-footed 
and  on  the  borders  of  their  feet  with  their  shoes  on.  Bath- 
ing the  feet  with  hot  and  cold  water  alternately  for  five 
minutes,  followed  by  vigorous  rubbing,  will  strengthen  the 
muscles. 

If  the  general  tone  is  low  the  improvement  in  the  gen- 
eral condition  will  have  a  correspondingly  beneficial  effect 
upon  the  condition  of  the  feet. 


CHAPTER  XVIII 

PREVENTION  OF  INFECTION  AND  BLEEDING  IN 
WOUNDS 

Sterilization  with  lodin,  Inflammation,  Sterilization  by  Washing. 
To  Prevent  Lockjaw.  Special  Wounds.  Bullet  Wounds.  To  Stop 
Bleeding. 

THERE  arc  two  methods  in  vogue  to  prevent  the  occur- 
rence of  inflammation  or  infection  in  wounds.  The  first 
is  most  recent  and  simple. 

Sterilization  of  Wounds  with  lodin. — This  is  applic- 
able in  wounds  and  cuts  of  all  kinds  where  there  is  not  so 
much  bleeding  as  to  demand  its  immediate  arrest. 

Apply  to  the  wound  itself  and  to  the  skin  immediately 
surrounding  it  the  pure  tincture  of  iodin  by  means  of  a 
small  piece  of  absorbent  cotton  wound  about  the  end  of  a 
stick,  match,  or  toothpick.  The  iodin  should  be  freely 
applied  so  as  to  cover  every  part  of  the  raw  tissue.  Wait  a 
few  minutes  until  the  iodin  is  dry  on  the  skin  and  then 
apply  an  absolutely  clean  or  sterile  dressing  and  bandage. 
If  sterile  gauze  is  not  at  hand,  one  may  use  cotton  cloth 
which  has  first  been  boiled  in  water  for  five  minutes.  A 
dry  dressing  is  better,  however.  In  placing  the  sterile 
gauze  or  cotton  over  the  wound  one  should  not  allow  one's 
fingers  to  touch  the  part  of  the  dressing  that  will  come  in 
contact  with  the  wound.  In  small  cuts  which  require  no 
covering  iodin  is  ideal  for  treatment. 

No  water  should  be  applied  to  a  wound  before  using 
iodin,  because  then  the  iodin  will  not  penetrate  into  the 
tissues  and  kill  germs.  When  the  skin  is  very  dirty  or 

330 


STERILIZATION    OF   WOUNDS    WITH    IODIN  331 

greasy  about  the  wound  it  is  well  to  wipe  it  off  with  alcohol 
or  benzin,  while  protecting  the  wound  by  covering  it  with 
a  bit  of  sterile  absorbent  cotton  or  sterile  gauze  before 
applying  the  iodin.  Then  when  the  skin  is  dry  apply  the 
iodin  to  the  wound  and  surrounding  skin.  If  there  are 
pieces  of  clothing,  hair,  splinters,  or  glass,  etc.,  in  the  wound, 
these  should  first  be  picked  out  with  forceps  or  hatpin 
before  applying  the  iodin. 

Tincture  of  iodin  is  the  most  valuable  first-aid  treatment 
for  all  wounds,  and  should  be  kept  on  hand  wherever  sur- 
gical accidents  are  likely  to  occur.  Some  smarting  is 
produced  by  the  application  of  iodin  to  fresh  wounds,  but 
this  is  temporary  and  not  severe.  In  a  recent  book  by  the 
present  Medical  Inspector  General,  Delorme,  of  the  French 
Army  (1915),  the  author  states  in  italics,  "Tincture  of  io- 
din is  at  present  the  best  and  safest  disinfectant  to  make 
use  of  in  the  practice  of  war  surgery,  both  in  the  fighting 
line  and  in  the  rear."  It  is  sometimes  inconvenient  for 
individuals  to  carry  about  on  their  persons  a  liquid  like 
the  tincture  of  iodin,  so  that  ointments  and  powders  may 
be  substituted  for  the  prevention  and  treatment  of  wound 
infections. 

Recent  experiments  in  this  country  indicate  that  an 
ointment  containing  10  per  cent,  each  of  tricresol  and 
thymol  may  be  safely  used  to  the  extent  of  a  dram  (or 
teaspoonful)  on  a  wound,  and  will  prove  as  effective  as 
tincture  of  iodin  in  preventing  infection.  The  bulk  or  base 
of  the  ointment  consists  of  castor  oil,  70  per  cent.;  white 
wax,  20  per  cent.;  and  spermaceti,  10  per  cent. 

Clean  wounds,  like  cuts  made  by  a  surgeon,  will  heal  at 
once  without  the  formation  of  pus  or  inflammation,  pro- 
viding cut  surfaces  are  brought  together  and  the  wound  is 
not  too  much  torn  or  bruised.  A  single  dressing  is  all 
that  is  required  in  such  cases,  and  it  is  always  advisable 


332  THE    PREVENTION    OF   DISEASE 

for  the  layman  to  leave  the  first  dressing  untouched  until 
the  wound  may  be  seen  by  a  surgeon,  even  if  a  week  or  more 
elapse,  if  there  is  no  fever,  great  pain,  or  certain  signs  of 
inflammation. 

In  place  of  stitches  the  layman  can  more  readily  use 
surgeon's  adhesive  plaster  to  close  wounds.  Strips  of 
plaster  3  inch  wide  and  long  enough  to  obtain  a  good 
hold  on  the  skin  (perhaps  2  inches  on  each  side  of  the 
wound)  should  be  laid  at  intervals  of  \  inch  across  the 
wound.  The  ends  are  firmly  pressed  down  on  one  side  of 
the  wound,  and  while  the  edges  of  the  wound  are  pinched 
together  the  free  ends  of  the  plaster  are  drawn  tightly 
across  the  wound  and  pressed  firmly  down  on  the  skin 
beyond.  Strips  of  plaster  should  never  completely  encircle 
a  limb  or  the  circulation  will  be  impeded.  Large  wounds 
should  only  be  closed  in  part,  leaving  an  inch  or  so  for 
drainage.  Small  punctured  wounds  should  not  be  closed 
at  all,  but  after  swabbing  them  deeply  with  iodin,  a  strip 
of  sterile  gauze  or  boiled  cotton  coth  should  be  pushed  to 
the  very  bottom  (by  a  boiled  hairpin)  to  secure  drainage 
before  covering  the  wound  with  dressing. 

Inflammation. — When  there  is  much  redness,  swelling, 
pain,  and  heat  about  a  wound  it  is  best  to  apply  a  moist 
dressing  until  inflammation  subsides.  Soak  sterile  gauze 
(or  boiled  cheese-cloth)  in  boiling  water  containing  as  much 
boric  acid  as  will  dissolve.  When  sufficiently  cool  wring 
the  water  out  of  the  gauze  slightly  with  the  clean  hands, 
being  careful  not  to  touch  the  part  of  the  gauze  which  will 
come  in  contact  with  the  wound.  Cover  the  wound  over  a 
large  area  with  the  dressing  an  inch  thick,  and  then  on  this 
lay  a  piece  of  oiled  silk  or  rubber  cloth  and  enclose  the 
whole  with  a  bandage.  Such  a  dressing  is  an  absolutely 
harmless  antiseptic  poultice  and  will  remain  moist  for 
twenty-four  hours,  when  it  may  be  replaced. 


TO    PREVENT   LOCKJAW  333 

Sterilization  of  Wounds  by  Washing. — The  older  method 
consists  in  washing  wounds  for  fifteen  minutes  or  so  until 
all  dirt  and  germs  are  removed.  This  is  an  efficient  treat- 
ment, but  requires  some  knowledge  and  skill  to  perform 
properly.  Antiseptic  solutions  are  often  used,  but  water 
to  which  salt  is  added  (1  level  teaspoonful  to  the  pint)  and 
that  has  been  boiled  five  minutes  and  allowed  to  cool  suffi- 
ciently, is  just  about  as  efficacious.  Pouring  the  water 
warm  from  a  clean  pitcher  in  a  small  stream  upon  the 
wound  is  one  of  the  best  methods,  as  one  does  not  convey 
any  germs  to  the  wound  with  the  hands. 

If  there  is  much  bleeding,  water  should  be  used  as  hot 
as  can  be  borne.  If  the  skin  is  very  dirty  surrounding  the 
wound  cover  the  wound  first  with  a  piece  of  sterile  gauze 
or  boiled  cotton  cloth  to  protect  it,  and  then  wash  the 
skin  thoroughly  with  soap  and  water,  and  finally  with  alco- 
hol diluted  one-third  with  water.  If  there  is  much  hair 
about  the  wound,  as  on  the  head,  this  must  also  be  cut  or 
shaved  off  for  about  an  inch  around  the  wound.  The 
more  thorough  or,  in  other  words,  the  longer  the  washing  is 
conducted  (from  ten  to  twenty  minutes),  the  better  will  be 
the  result.  In  case  it  is  necessary  to  remove  some  dirt  or 
clots  that  cannot  be  washed  off,  one  may  boil  some  pieces 
of  absorbent  cotton  or  old  cotton  cloth  for  five  minutes, 
and  after  washing  one's  hands  for  the  same  length  of  time 
may  bathe  the  wound  and  rub  off  the  dirt  or  clots  with  these 
as  sponges.  Then  the  wound  should  be  covered  with  dry 
sterile  gauze  or,  lacking  this,  wet  cotton  cloth  after  boiling 
it  for  five  minutes.  The  part  of  the  sterile  gauze,  or  boiled 
cotton  cloth,  which  will  touch  the  wound  should  not  first 
come  in  contact  with  the  fingers. 

To  Prevent  Lockjaw. — Punctured  wounds  of  the  hands 
or  feet  soiled  with  street  or  stable  dirt  are  especially  liable 
to  lockjaw  unless  properly  handled.  Any  wounds  much 


334  THE    PREVENTION    OF   DISEASE 

bruised  or  torn  are  also  more  subject  to  this  infection. 
The  reader  is  referred  to  page  96  for  means  of  absolutely 
preventing  this  fearful  complication. 

Special  Wounds. — In  deeply  cut  wounds  of  the  hands  it 
is  not  sufficient  that  the  wound  be  closed  by  stitches,  but 
nerves  and  tendons  must  be  properly  united  or  some  of  the 
fingers  may  be  useless.  This  is  work  for  an  able  surgeon 
and  the  general  practitioner  not  infrequently  fails  to 
secure  good  results  in  these  cases.  Ragged,  bruised  wounds 
should  be  swabbed  with  iodin  and  left  open  to  a  con- 
siderable extent  for  drainage. 

Punctured  wounds  made  by  nails,  splinters,  knives, 
and  teeth  of  animals  are"  among  the  most  difficult  for  the 
layman  to  treat  properly,  even  in  the  way  of  a  first  dressing. 
Unless  made  by  a  small,  very  clean  body,  as  a  needle,  such 
wounds  must  be  swabbed  to  the  bottom  with  iodin  and 
kept  open  by  stuffing  in  strands  of  string  or  cotton  cloth 
which  have  been  boiled  five  minutes.  Iodin  may  be  ap- 
plied by  means  of  a  little  absorbent  cotton  wound  on  a 
toothpick.  The  toothpick  should  be  wet  before  twisting 
the  cotton  about  it  to  keep  the  cotton  from  coming  off  in 
the  wound. 

Punctured  wounds  so  small  that  one  cannot  swab  them 
out  with  iodin,  as  from  nails  or  bullets,  are  those  which 
especially  demand  immediate  surgical  attention  because 
germs  become  sealed  in  the  wound  and  inflammation  and 
lockjaw  may  result  (see  page  96).  The  moist,  antisep- 
tic dressing,  described  under  Inflammation,  is  often  best 
for  punctured  wounds.  Scalp  wounds  frequently  bleed 
freely.  The  bleeding  may  be  stopped  by  pouring  water 
as  hot  as. can  be  borne  over  the  wound  and  by  covering 
the  wound  with  a  pad  of  sterile  gauze  or  boiled  cotton 
cloth  and  holding  it  very  tightly  by  a  bandage  about  the 
head.  Iodin  is  the  best  agent  to  apply  when  bleeding  has 


BULLET    WOUNDS  335 

stopped.  The  hair  should  be  cut  off  for  2  inches  about  the 
wound,  which  maybe  closed  by  adhesive  plaster  (see  above) 
and  covered  with  dry  sterile  gauze  and  bandage. 

Bullet  Wounds. — Clothing  should  be  cut  away  about 
the  wound  and  the  wound  and  skin  (for  2  inches  around 
the  wound)  should  be  painted  with  tincture  of  iodin.  As 
soon  as  the  iodin  is  dry  a  pad  of  at  least  an  inch  in  thick- 
ness should  be  bandaged  snugly  over  the  wound.  The 
pad  had  best  consist  of  sterile  gauze,  but  in  its  absence, 
old  cotton  cloth  which  has  been  boiled  five  minutes  or 
sterile  absorbent  cotton  may  be  used.  The  patient  should 
be  kept  absolutely  quiet  in  bed,  as  shock  is  common. 

If  a  limb  is  wounded  it  is  well  to  apply  some  sort  of  a 
splint  made  of  thin  board,  padded  with  folded  sheets,  to 
keep  the  wound  at  absolute  rest. 

Shock  is  shown  by  pallor,  cold  hands  and  feet,  and 
weak,  rapid  pulse.  The  patient  should  be  given  4  table- 
spoonfuls  of  whisky  in  an  equal  amount  of  hot  water 
and  be  surrounded  by  hot-water  bags. 

Probing  for  bullets  should  never  be  undertaken  by  the 
layman  and  is  usually  undesirable  on  account  of  the  danger 
of  pushing  germs  into  the  wound.  The  axray  is  employed 
to  locate  bullets.  Bullets  are  sterilized  to  some  extent  by 
the  scraping  they  get  and  the  heat  generated  in  the 
weapon,  but  if  they  carry  any  clothing  into  the  wound 
inflammation  is  almost  sure  to  result. 

Where  a  bullet  passes  through  the  body  the  wound  of 
exit  is  usually  larger  and  more  ragged  than  the  wound  of 
entrance.  If  a  person  is  hit  by  a  charge  of  shot  from  a 
shot-gun  at  close  range  a  dreadful  wound  is  produced. 
Bleeding  must  be  stopped  (see  below),  the  cavity  thor- 
oughly swabbed  with  iodin,  and  packed  loosely  with  sterile 
gauze  or  boiled  cotton  cloth,  and  covered  with  a  thick 
pad  of  the  same  and  bandage.  Bullet  wounds  of  the  head, 


336  THE    PREVENTION   OF   DISEASE 

chest,  and  abdomen  are  naturally  the  most  serious  and 
demand  instant  surgical  attendance. 

To  Stop  Bleeding. — Keep  cool.  An  adult  may  lose  1  to 
2  pints  of  blood  without  danger. 

When  Bright  Red  Blood  is  Flowing  in  Spurts. — Place 
the  patient  on  his  back  and  make  firm  pressure  with  both 
thumbs  into  the  flesh  just  above  the  wound,  that  is,  nearest 
the  body.  An  assistant  should  then  tie  a  tight  bandage 
about  the  limb  between  the  wound  and  the  body — an 
elastic  pair  of  suspenders  or  (best)  a  piece  of  rubber  tubing. 
Or  a  rope  or  strap  may  be  fastened  tightly  over  a  folded 
towel,  to  prevent  injury  of  the"  skin.  A  folded  towel  or 
handkerchief  may  be  twisted  tightly  about  the  limb  with 
a  stick.  A  pad  of  sterile  gauze,  rounded  stone,  or  cork, 
under  the  bandage  and  over  the  wound,  may  help  to  plug 
the  opening.  A  tight  bandage  (or  tourniquet)  may  be 
kept  on  a  limb  for  an  hour  without  doing  serious  damage 
to  the  tissues.  A  bleeding  arm  or  leg  should  always  be 
held  well  up  in  the  air  resting  upon  some  extemporized 
support.  Spurting  blood  comes  from  an  artery. 

To  Stop  Steady  Flow  of  Dark  Blood. — Make  firm  press- 
ure with  a  pad  of  sterile  gauze,  or  absorbent  cotton,  or 
clean  handkerchief  wet  with  alcohol,  directly  over  the 
wound.  This  may  be  held  in  place  with  a  tight  bandage. 
Raise  the  limb  on  a  support.  If  the  flow  of  blood  is  large 
tie  a  tight  bandage  about  the  limb  below  the  wound,  that 
is,  farthest  from  the  body.  This  may  be  removed  in  half 
an  hour.  Steady  flow  of  dark  blood  comes  from  a  vein 
bringing  blood  toward  the  body  and  heart.  Spurts  of 
bright  red  blood  come  from  an  artery  bringing  blood  away 
from  the  body  and  heart. 

To  Stop  Constant  Oozing  of  Blood. — This  means  that 
small  vessels  are  cut,  and  bleeding  may  be  expected  to 
stop  through  clotting  of  blood  and  contraction  of  the  cut 


TO    STOP    BLEEDING  337 

ends  of  the  ^vessels.  If  it  persists,  pouring  water  as  hot  as 
can  be  borne  upon  the  wound  may  stop  the  bleeding,  or 
constant  pressure  made  on  a  pad  of  sterile  gauze,  absorb- 
ent cotton,  or  folded  handkerchief  wet  in  alcohol  will  ar- 
rest it. 

Ice-water  at  hand  may  be  used  in  place  of  hot  water, 
although   the   latter   is   preferable.     The   bleeding   limb 
should  be  elevated. 
22 


INDEX 


ABSCESS  of  teeth,  147,  159 
Adenoids  and   tonsils,   diseased, 

cause  of,  154 
how  to  detect,  154 
remote  effects  of,  121,  130, 
131,  146,  147,  152,  153, 
155,  158,  205,  224 
removal  of,  155 
Alcohol,  action  of,  7 

on  circulation,  9,  10 
on  mental  efficiency,  8 
on  muscular  system,  9 
on  nervous  system,  8 
on  stomach,  11 
on  temperature  of  body,  10 
as  a  food,  1 1 
as  a  poison,  11 
as  a  stimulant,  9 
bad  effects  of,  11 
composition  of  various  drinks, 

5,  6,  7 

summary  of  action,  12 
Amebic  dysentery,  85 
Ankles,  rheumatism  of,  327 
weak,    325.      See    also    Weak 

ankles. 

Appendicitis,  cause  of,  152,  272 
Armpits,  perspiring,  57 
Arteriosclerosis,  228 
blood-pressure  in,  234 
estimation  of,  235 
high,  234 


Arteriosclerosis,  causes  of,  228- 
232,  244 

constipation  in,  260 

diet  in,  240 

drinking  in,  242 

examination  for,  annual,  238 

exercise  in,  239 

prevention  of,  238 

work  in,  243 
Asiatic  cholera,  82 
carriers  of,  82 
how  communicated,  82 
means  of  preventing,  82,  83 
vaccination  against,  83 
Asthma,  cause  of,  153 

BACILLARY  dysentery,  85 

Baldness,  69 

Barber,  diseases  acquired  from, 

69 
Baths,  58 

cabinet,  58 

cold,  59 

hot,  63 

hot-air,  63 

lukewarm,  62 

outdoor,  59 
dangers  of,  61 

sea,  59 

Turkish,  63 

warm,  62 
Beriberi,  297 

339 


340 


INDEX 


Beriberi,  cause  of,  297 

symptoms  of,  300 

vitamins  in,  297 
Bleeding,  to  stop,  336 
Blood-pressure,  234 

estimation  of,  235 

high,  234 

significance  of,  234 
Bow-legs,  324 

causes  of,  324 

prevention  of,  325 

treatment  of,  325 
Breakbone  fever,  115 
Bright's  disease  of  kidney,  230, 

237 

causes  of,  237 
prevention  of,  238 
Bubonic  plague,   104.     See  also 

Plague. 
Bullet  wounds,  335 

CAFFEIN,  1,  5 
Cancer,  classes  of,  163 

cures  possible,  164,  167,  169 

early  signs  in,  163 

frequency  of,  165 

heredity  in,  177 

immunity  in,  176 

injury  as  cause  of,  168,  169 

mortality  in,  165,  178 

of  appendix,  174 

of  breast,  160,  169 

of  colon,  162 

of  face,  175 

of  gall-bladder,  174 

of  lip,  160,  174 

of  mouth,  160,  169 

of  rectum,  162 

of  skin,  160,  169,  174 

of  stomach,  162,  171,  271 

of  thyroid,  161 


Cancer  of  tongue,  160,  175 
of  womb,  161,  173 
precancerous  stage  of,  163 
Canned    food,    poisoning    from, 

292,  293 

Cerebrospinal  meningitis,  137 
curriers  in,  139 
prevention  of,  139 
serum  cure  of,  138 
symptoms  of,  137 
vaccination  in,  141 
Chest,  rheumatism  of,  210 
Children,  adenoids  in,  153,  224 
circumcision  in,  214 
colds  in,  130,  223,  225 
constipation  in,  269 
feeding  of,  217,  221 
fevers  in,  223,  224 
indigestion  in,  276 
malaria,  107 
mortality  in,  214,  215 
nervous,  247,  248 
sexual  hygiene  of,  193 
sickness  of,  224 
teeth  in,  20,  225 
tonsils  in,  153,  224 
vaccination  against  smallpox, 

71 

typhoid,  76 
Chocolate,  action  and  uses,  3 

composition  of,  3 
Cholera,  Asiatic,  82 
carriers  of,  82 
how  communicated,  82 
means  of  preventing,  82,  83 
vaccination  against,  83 
Chorea,  207 
Circumcision,  214 
Clothing  for  hot  weather,  57 
for  women,  56 
in  winter,  58 


INDEX 


341 


Clothing  of  cotton,  57 

of  linen,  57 

of  silk,  57 

of  wool,  57 

underclothing,  56 
Coffee,  action  of,  4 

bad  effects  of,  4 

caffein  in,  1 

composition  of,  2 

excessive  use  of,  5 

habitual  use  of,  5 

susceptibility  to,  3 
Cold  in  head,  130 

avoidance  of,  131 
causes  of,  130 
prevention  of,  131,  134 
remedies  in,  132 
treatment  of,  132,  133 
Colds,  130 
Complexion,  66 

endangered  by  barber,  69 

eruptions  on,  67 
Conception,  when  likely  to  occur, 

201 
Constipation,  260 

causes  of,  261,  262 

definition  of,  261 

diet  in,  263 

drugs  in,  265 

exercise  in,  267 

in  children,  269 

injections  in,  269 

massage  in,  268 

mineral  waters  in,  265 

prevention  of,  262 

symptoms  of,  260,  269 

with  colic,  269 
Consumption,     117.       See    also 

Tuberculosis. 
Cooking,  broiling,  29 

frying,  29 


Cooking  influences  digestion,  29 

roasting,  29 

stewing,  29 
Cows,  tuberculosis  in,  120,  285 

udder  disease  in,  286 
Curvature,  lateral,  of  spine,  318 
Cuts,  330.    See  also  Wounds. 

DANDRUFF,  68 

Dandy  fever,  115 

Deafness,  prevention  of,  155,  322 

Deformities,  prevention  of,  317 

Dementia,  precocious,  256 

senile,  258 
Dengue,  115 
cause  of,  115 
prevalence  of,  116 
prevention  of,  116 
symptoms  in,  116 
Diabetes,  prevention  of,  316 
Diet,  30.     See  also  Food. 
calories  required  daily,  46 
of  fruit,  39 
salt  essential  in,  42 
vegetarian,  34,  41 

vs.  meat,  41 

Digestion  in  intestines,  28 
in  mouth,  25 
in  stomach,  27 
influenced  by  cooking,  29 
by  dress,  45 
by  emotion,  27 
by  mealtimes,  45 
by  posture,  45 
Digestive  diseases,  271 
functional,  271 
organic,  271 
reflex  or  secondary,  271 
Diphtheria,  86 
antitoxin  in,  86 

as  preventive,  87,  89 


342 


INDEX 


Diphtheria,  antitoxin  in,  dangers 

of,  87 
for  treatment,  87 

carriers  of,  89 

from  milk,  285 

how  acquired,  89 

susceptibility,  Schick's  test,  90 

vaccination  against,  91 
Dysentery,  84 

amebic,  85 

bacillary,  85 

carriers  of,  85 

how  acquired,  84 

prevention  of,  85 

symptoms  of,  84 

vaccination  against,  85 
Dyspepsia,  271 

nervous,  273 

ERYSIPELAS,  cause  of,  152 
Examination,  physical,  238 
Exercise  by  correspondence,  48 

college,  48 

dangers  of,  54 

fatigue  from,  49,  51 

for  constipation,  267 

for  different  ages,  47 

for  elderly,  50 

for  flat-feet,  329 

for  general  development,  55 

for  middle  aged,  50 

for  obesity,  315 

for  youth,  48 

influence  on  body,  50 
on  breathing,  52 
on  heart,  52 
on  nervous  system,  50,  51 

school,  48 

FACE,  acne  on,  67 

eruptions  on,  from  barber,  69 


Face,  pimples  on,  67 

powders,  66 
Fatness,  307 
Feeding  infants,  orange  juice  in, 

220,  221,  303 
pasteurized  milk  for,  220 
simple  formulae  for,  217-221 
Feet,  flat-,  325.     See  also  Flat- 
feet. 

perspiring,  57 

rheumatism  of,  327 
Finger-nails,  care  of,  70 
Fish  poisoning,  293 
Flat-feet,  325 

diagnosis  of,  327 

exercises  for,  329 

massage  in,  329 

prevention  of,  328 

symptoms  in,  327,  328 
Flatulence,  intestinal,  232 
Fleas  as  cause  of  bubonic  plague, 

105 
Food,  absorption  of,  30 

poisoning,  283 

symptoms  of,  290 
Freckles,  67 
Fruit  poisoning,  294 

GALL-BLADDER        inflammation, 

cause  of,  148,  152 
remote  effects  of,  157 
Gall-stones,  272 
Gastritis,  272 
Glands,  enlarged,  150,  152 
tuberculous,  119 

treatment  of,  128 
Goiter,  cause  of,  152 
Gonorrhea,  chronic,  detection  of, 

190 

period  of  development,  181 
prevention  of,  191,  192 


INDEX 


343 


Gonorrhea,    remote    effects    of, 

180,  181 

symptoms  of,  181 
Gout,  rheumatic,  208 
Grippe,  135 

HAIR,  care  of,  68 

to  prevent  falling,  68 
Hardening  of  arteries,  228.     See 

also  Arteriosclerosis. 
Heart  disease,  236 

causes  of,  149,  232-236 
prevention  of,  236-238 
Hemorrhage,  to  stop,  336 
Humpback,  321 
Hydrophobia,    diagnosis    of,    in 

dogs,  94 
frequency  of,  92 
period  of  development,  94 
symptoms  in  dogs,  92 
treatment  of  dog  bite,  94 
vaccination  against,  94 
effects  of,  95 

ICE,  dangers  of,  45 
in  cooling  water,  45 
to  know  when  safe,  45 
Ice-cream  poisoning,  288 
Indigestion,  271 
causes  of,  26 
nervous,  273 
Infant  feeding,  formulae  for,  217- 

221 

orange  juice  in,  220,  221,  303 
pasteurized  milk  in,  220 
Infantile  paralysis,  141 
carriers  in,  141 
germ  of,  142 

how  conveyed  to  persons,  142 
path  of  entrance  to  body,  142 
period  of  development  of,  142 


Infantile    paralysis,     prevention 

of,  143 

symptoms  of,  143 
Infants,  prevention  of  disease  in, 

213 
Infection  in  wounds,  prevention 

of,  330-333 

Inflammation  in  wounds,  332 
Influenza,  135 

causes  of,  135 

contagiousness  of,  135 

definition  of,  135 

development  period  in,  137 

prevention  of,  136 
Insanity,  253 

causes  of,  254 
alcohol,  254 
syphilis,  255 

heredity  in,  254 

manic-depressive,  257 

prevention  of,  246 

treatment  of,  258 
Intestinal  flatulence,  232 

putrefaction,  232 
lodin  in  wounds,  330 

JOINTS,  inflamed,  causes  of,  151, 
158 

KIDNEY,  Bright's  disease  of,  230, 

237 

causes  of,  237 
prevention  of,  238 
stone  in,  272 
Knees,    knock-,    324.     See   also 

Knock-knees. 
Knock-knees,  324 
causes  of,  324 
prevention  of,  325 
treatment  of,  325 


344 


INDEX 


LATERAL  curvature  of  spine,  318 
Legs,  bow-,  324.     See  also  Bow- 
legs. 

rheumatism  of,  327 
Lockjaw,  95 

antitoxin  in,  96 
how  made,  97 

how  acquired,  96 

prevention  of,  96 

wounds  predisposing  to,  96 
Locomotor  ataxia,  183 
Longevity  and  marriage,  201 

in  various  countries,  214 
Lumbago,  209 

MALARIA,  107 

cause  of,  107 

how  acquired,  108 

methods  of  preventing,  108 

quinin  in,  111 

where  prevalent,  112 
Marriage  and  longevity,  201 

sexual  hygiene  in,  197 
Masturbation,  193 

circumcision  for,  193 

prevention  of,  193 

remote  effects  of,  194,  195 

treatment  of,  196 
Measles,  100 

contagious  period  of,  100 

development  period  in,  100 

isolation  required,  101 

mortality  in,  100,  101 

prevention  of,  101 
Meat  poisoning,  290 
Mental  disease,  prevention  of, 

246 
Milk,  bacteria  in,  284 

diarrhea  (infantile)  from,  284 

diphtheria  from,  285 

dirt  in,  284,  286 


Milk,  food  value  of,  36 
for  infant  feeding,  217,  221 
pasteurization  of,  286,  287 
Freeman's  home,  288 
home,  287 
poisoning,  284 
scarlet  fever  from,  285 
septic  sore  throat  from,  286 
to  aid  digestion  of,  36 
to  fatten  invalids,  36 
tonsillitis  from,  286 
tuberculosis  from,  285 
typhoid  fever  from,  285 
Mortality  rates,  214 

from  tuberculosis,  214 
in  infants,  215 

reduction  in,  216 
Mosquitoes,  dangers  of,  107,  112, 

115 
Mouth  infection,  145 

significance  of,  145 
pus  germs  in,  148 
Mumps,  101 

complications,  102 
contagious  period,  101 
development  period,  101 
duration  of,  102 
Muscular  rheumatism,  209 
Mushroom  poisoning,  294 

NERVOUS  children,  rearing  of,  247 
diseases,  prevention  of,  246 
dyspepsia,  273 
indigestion,  273,  282 

build  in,  276 

causes  of,  277,  279 

diagnosis  of,  279 

heredity  in,  277 

posture  favoring,  277,  280 

symptoms  of,  278 

surgery  in,  281 


INDEX 


345 


Nervous   indigestion,   treatment 

of,  279 
prostration,  247 

causes  of,  247,  253 

prevention  of,  248,  253 

symptoms  of,  251 
Neurasthenia,  247 
Neuritis,  causes  of,  152 
Nose  infections,  145 

significance  of,  145 

OBESITY,  307 

Bouchard's  cure,  312 

causes  of,  307 

diseases  in,  307 

Ebstein's  cure,  312 

effecting  life,  307 

effects  of,  309 

exercise  in,  315 

glandular  secretions  in,  309 

Locke's  cure,  313 

milk  cure  in,  312 

Oertel.cure  in,  311 

reduction  of,  310 

symptoms  in,  309 

water  in,  315 
Old  age,  dangers  in,  238 

deferred,  238,  244.    See  also 

Arteriosclerosis,  228 
Opium  habit,  19 
Orange  juice  in  infant  feeding, 

220,  221 
preventing  scurvy,  303 

PARALYSIS,    infantile,    141.     See 

also  Infantile  paralysis. 
Paranoia,  symptoms  of,  256,  257 
Paresis,  183,  255 
Pasteurization  of  milk,  286,  287 
Freeman's     home     method, 
288 


Pasteurization  of  milk,  home,  287 
Pellagra,  causes  of,  306 

symptoms  of,  305 

vitamins  in,  306 
Perspiration  of  armpits,  57 

of  feet,  57 

Physical  examinations,  238 
Plague,  104 

contagion  in,  105 

countries  invaded,  105 

Haffkine's  vaccine  in,  106 

how  acquired,  105 

prevention  of,  106 

symptoms  of,  105 
Pneumonia  germs  in  mouth,  148, 

152 

Poliomyelitis,  141.     See  also  In- 
fantile paralysis. 
Potato  poisoning,  296 
Poultice,  antiseptic,  331 
Pregnancy,  prevention  of,  200 
Ptomain  poisoning,  289 
Putrefaction,  intestinal,  232 
Pyorrhea,-22,  147,  158 

RABIES,  92 
diagnosis,  93 
dumb,  93 
symptoms  of,  92 
Rachitis,  302.     See  also  Rickets. 
Rheumatic  gout,  208 
Rheumatism,  acute,  203 
causes,  203,  205 
prevention  of,  207 
symptoms,  203 
cause  of,  151 
chronic,  207 
causes  of,  208 
prevention,  208 
muscular,  209 
.  of  ankles,  327 


346 


INDEX 


Rheumatism  of  chest,  209 
of  feet,  327 
of  legs,  327 
Rickets,  302 
causes  of,  302 
prevention  of,  304 
symptoms  of,  304 
Riggs'  disease  of  gums,  22,  147, 

158 

causes  of,  23 
cure  of,  24 
prevention  of,  25 
.   remote  effects  of,  24 
Round  shoulders,  318 
effects  of,  318 
prevention  of,  322 
symptoms  of,  319 
treatment  of,  322 

SCARLATINA,  97.    See  also  Scarlet 

fever. 

Scarlet  fever,  97 
carriers  of,  98 
development  period,  98 
disinfection  in,  99 
how  acquired,  98 
isolation  period,  99 
prevention  ,  99 
susceptibility  to,  97 
Scurvy,  301 
cause  of,  301 
cure  of,  301 
in  infants,  302 
prevention  of,  303 
symptoms  of,  302 
prevention  of,  301 
symptoms,  301 
vitamins  in,  301 

Self  abuse,  193.     See  also  Mas- 
turbation. 
Sexual  diseases,  180 


Sexual  diseases,    prevention   of, 

185 

hygiene  in  children,  193 
in  marriage,  197 
in  youth,  193 

Shell-fish  poisoning,  293 

Shoulders,  round,  318.    See  also 

Round  sfioulders. 
stoop,  318 

Skin,  eruptions  of,  66 
to  prevent,  67 

Smallpox,  inoculation  against,  71 
prevention  of,  71 
preventive  measures,  75 
test  for  susceptibility,  73 
vaccination  against,  72 

Soaps,  66 

Spine,  curvature  of,  318 

Stiff  neck,  209 

Stomach,  cancer  of,  162,  171,  271 
ulcer  of,  271 

Stoop  shoulders,  318 

Stone  in  kidney,  272 

Stoutness,  307.     See  also  Obesity. 

Strawberries,  poisoning  by,  295 

St.  Vitus'  dance,  207 
cause  of,  151 

Sunburn,  67 

Swimming  pools,  diseases  from, 
62 

Syphilis,  contagious  period,  183 

in  mothers,  183 
hereditary,  183 
how  acquired,  182 
locomotor  ataxia  in,  183 
marriage  in,  189 
paresis  in,  183 
period  of  development,  182 
prevalence  of,  184,  185 
prevention  of,   185,   188,   190, 
192 


INDEX 


347 


Syphilis,  stages  in,  182 

Wassermann  test  in,  184,  189 

TEA,  action  of,  4 

bad  effects  of,  4 

caffein  in,  1 

composition  of,  2 

excessive  use  of,  5 

habitual  use  of,  5 

susceptibility  to,  3 

tannin  in,  2 
Teeth,  abscess  of,  147,  159 

adenoids  affecting,  21 

brushing,  22 

care  of,  21,  22 

cause  of  serious  diseases,  147, 
159 

dental  floss  in  care  of,  22 

irregular,  21 

protruding,  21 

Riggs'    disease    of,    22,    147, 
158 

straightening,  21 

toothpicks,  22 

Tetanus,  95.     See  also  Lockjaw. 
Throat,  infection  of,  145 
from  milk,  285,  286 
significance  of,  145 
Tobacco,  action  of,  13 

composition  of,  16 

effect  in  cigarettes,  16,  17 
in  cigars,  16,  17 
in  pipes,  16 
on  efficiency,  18 

ill  effects  of,  14 

psychic  effects  of  smoking,  17 
Toe-nails,  care  of,  70 
Toilet  powders  and  soaps,  66 
Tonsillitis,  acute,  210 

from  milk,  286 

prevention  of,  211 


Tonsils  and  adenoids,  diseased, 

cause  of,  154 
how  to  detect,  154 
remote  effects  of,  121, 130, 
131,  146,  147,  152,  153, 
155,  158,  205,  224 
removal  of,  155 
tuberculous,  152 
Tuberculosis,  117 
acute  form,  124 
age  when  it  begins,  118 
build  susceptible  to,  119 
care  of  patients,  127 
causes  of,  121 
conditions  favoring,  124 
disinfection  in,  129 
early  symptoms  of,  125 
from  milk,  120,  285 
immunity  to,  122 
in  children,  119,  121,  125 
in  cows,  120,  285 
inheritance  of,  118 
marriage  in,  127 
mortality  in,  117 
occupations  favoring,  123 
of  glands,  119 
paths  of  entrance  of,  119 
percentage  attacked,  118 
prevention  of,  125,  128,  130 
treatment       of       tuberculous 

glands,  128 
Tuberculous  glands,  119 

treatment  of,  128 
Typhoid  fever,  76 
carriers  of,  80 
from  milk,  285 
how  acquired,  78 
means  of  contagion,  78, 79, 81 
vaccination  against,  76 

period  of  protection  by, 
78,  81 


348 


INDEX 


ULCER  of  stomach,  271 

and  duodenum,  cause  of,  152 
cancer  following,  272 
causes  of,  149,  272 
medical  cures  in,  271 
surgical  cures  in,  271 

Underclothing,  56 

VACCINATION     against     cerebro- 

spinal  meningitis,  141 
against  cholera,  83 
against  diphtheria,  86,  91 
against  dysentery,  85 
against  hydrophobia,  94 
against  lockjaw,  95 
against  plague,  106 
against  smallpox,  72 

dangers  of,  74 

origin  bf,  72 

period  of  protecting,  73 

proof  of  value,  75 

technic  of,  74 

vaccine  matter,  73 
against  typhoid  fever,  76 
against  whooping-cough,  104 
Vegetables,  poisoning  by,  294 
Ventilation,  64 
Vitamins,  297 

absent  in  pasteurized  milk,  302 

in  beriberi,  297 

in  pellagra,  306 

in  rickets,  304 

in  scurvy,  301 

lack  of,  300 

WASSERMANN    test    in    syphilis. 
184,  189 


Water,  dangers  from,  43 
in  daily  diet,  42 
supply,  43 
from  wells,  43 
purified  by  bleach,  44 
by  boiling,  44 
by  filtering,  44 
Weak  ankles,  325 
exercises  for,  329 
massage  for,  329 
prevention  of,  328 
symptoms  of,  327,  328 
Weight  of  body,  normal,  tables 

for  height  and  age,  308 
Whooping-cough,  102 
development  period,  103 
disinfection  in,  104 
mortality  in,  102 
prevention  of,  104 
symptoms  in,  103 
vaccination  against,  104 
Wounds,  bullet,  335 
dressing  for,  330 
inflammation  in,  332 
iodin  in,  330 
lockjaw  in,  330 
stitching,  332 
to  prevent  infection  of,   330, 

333 
treatment  of,  330,  333 

YELLOW  fever,  112 
cause  of,  112 
how  to  avoid,  112 
prevention  of,  114 
symptoms  of,  ll4 
where  prevalent,  114 


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